New Client Form

New Client Form

"*" indicates required fields
Owner Information

Payment is required when services are rendered.
Name

First NameLast Name
Preferred Phone Number
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Alternate Phone Number
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone
Please enter a valid phone number.Format: (000) 000-0000.
Preferred Method of Contact
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Is anyone in your household over 65 years old, military or veteran?
Would you like to add an additional owner to your pets account?
Spouse/Secondary Owner

First NameLast Name
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Other Phone
Please enter a valid phone number.Format: (000) 000-0000.
Previous Veterinarian/Clinic
May we request records from the above listed location?
Do you already have an appointment booked with us?
If not, what are your preferred appointment times?
Ex. Tuesday mornings or any day after 2pm
Pet Information
Pet #1 Name
Is this pet microchipped?
Pet #1 Species
Pet #1 Breed
Pet #1 Color
Pet #1 DOB/Age
Pet #1 Sex
Any additional pets that will be seen with us?
Pet #2 Name
Is this pet microchipped?
Pet #2 Species
Pet #2 Breed
Pet #2 Color
Pet #2 DOB/Age
Pet #2 Sex
Pet #3 Name
Is this pet microchipped?
Pet #3 Species
Pet #3 Breed
Pet #3 Color
Pet #3 DOB/Age
Pet #3 Sex
Are any of your pets on medication (list)?
Are any of your pets allergic to medication/vaccines (list)?
Do any of your pets have any major medical problems (list)?
We offer 10% discount for Military/Veterans, Senior Citizens, and Service Dogs. We accept check, cash, Visa, MasterCard, Discover, American Express, and CareCredit. Monthly payment plans are available through Cherry with no hard credit checks; learn more at mahometanimalhospital.com/payment-plans

Account balances will be charged a $1 statement handling fee & 2% interest monthly. Any returned checks will result in a $25 service charge.
Text me reminders
How did you hear about us?

Other
If you were referred, please share the name so we can thank them.
Media Consent and Release Form
I, First Name ,give my consent to Mahomet Animal Hospital, its affiliates and agents, to use my image(s) and any interview statement(s) from me and my pet(s) taken in or around the hospital in its publications including:
This consent includes, but is not limited to (check all that apply):

Other
I hereby waive any right to inspect or approve the finished photographs or electronic matter that may be used in conjunction with them now or in the future, whether that use is known to me or unknown, and I waive any right to royalties or other compensation arising from or related to the use of the image(s).
Please provide your tagging information for TikTok, Facebook, and Instagram.
I, First Name ,do not give consent to Mahomet Animal Hospital, to use my image(s) and any interview statement(s) from me and my pet(s) taken in or around the hospital in its publications.
Client Name:
Client Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
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New Client Form

Owner Information

Pet Information

Media Consent and Release Form