New Client Registration Form

May 9, 2022

We are NOT accepting new clients with dog or cat patients at this time. If you fill out this form for a dog or cat, we will NOT be calling you to schedule.

We ARE accepting rabbit, guinea pig and pocket pet new patients. If you have one of these species, we will call you to schedule – please be patient, it may take a few days for us to activate your account and get back to you.
New Client Form:
Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
E-mail
example@example.com
Spouse/Other Name

First NameLast Name
Spouse/Other Phone
Please enter a valid phone number.
How did you hear about us?*
Other
Pet 1 Name*
Species*
Other
Breed*
Color*
Age or Birthdate*
Sex*
Where may we call for previous veterinary records?
Pet 2 Name
Species
Other
Breed
Color
Age or Birthdate
Sex
Where may we call for previous veterinary records?
Pet 3 Name
Species
Other
Breed
Color
Age or Birthdate
Sex
Where may we call for previous veterinary records?
Due to the number of "No Shows", we are requiring pre-payment of the Physical Exam charge at the time of scheduling the appointment. Payment will be forfeited if appointment is missed or not rescheduled within one working day (Monday through Friday) prior to appointment. All additional fees are due at time of service. Please indicate choice of payment.*

CashCheckVisaMastercardDiscoverDebit CardCare Credit
Please provide reason for scheduling appointment and for which pet.
Which number should we call to schedule the appointment?*
What is the best time to call you? (Our calls are made between 8am-6pm Monday through Friday)*
Should be Empty:

New Client Form: