New Client Form

New Client Form

We are excited to meet you and your pets!
A quick little note:

VetMobile is a veterinary service based in Little Rock that provides in-home, non-emergency care for dogs, cats, and small exotic pets (birds, reptiles, and small mammals). Our boundaries are roughly Mayflower to the North, Sherwood to the East, Benton to the South, and Williams Junction to the West. We hope this information is helpful!
Full Name (primary)

First NameLast Name
Primary Contact Number
Please enter a valid phone number.
Primary Email Address
example@example.com
Full Name (secondary)

First NameLast Name
Secondary Contact Number
Please enter a valid phone number.
Secondary Email Address
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How do you prefer to be contacted?

Phone CallsText MessagesEmailsPost Cards
How did you find us? If you were referred by a friend, please list their name so we can tell them thank you.
Previous Veterinary Clinic Name
We will request a copy of your pet's medical record
Pet Name: Name Species: Species Breed: Breed
Sex: Age/DOB: Age or DOB
Pet Name: Name Species: Species Breed: Breed
Sex: Age/DOB: Age or DOB
Pet Name: Name Species: Species Breed: Breed
Sex: Age/DOB: Age or DOB
Pet Name: Name Species: Species Breed: Breed
Sex: Age/DOB: Age or DOB
Pet Name: Name Species: Species Breed: Breed
Sex: Age/DOB: Age or DOB
Pet Name: Name Species: Species Breed: Breed
Sex: Age/DOB: Age or DOB
What services are you interested in?

Wellness Care (annual exams, vaccines, heartworm tests, etc.)Minor ailments (bumps, new infections, anal glands, etc.)Exotic Animal Care (birds, reptiles, pocket pets)Post-surgery rehabilitation exercisesEnd-of-life / Hospice CareEuthanasia
Does anyone in the household (people and animals) have life-threatening allergies including, but not limited to, medications, food, disinfectants? Please briefly list them below so we can keep your family safe.
While we love to show off our patients, we will protect you and your pet’s privacy. We will NEVER share your contact information, last names, and/or sensitive medical information about your pets on any of our platforms. Any medical information will be vague and non-identifying.
I consent to having my pet's photo taken and used for social media, educational materials, and/or marketing. I understand my pet's name may be used and a vague description of their medical needs.

YesNo
I, the undersigned, authorize medical treatment of my pet(s) by the doctors of VetMobile and agree to pay all fees associated with that care regardless of estimated costs, which are subject to change based on the needs of my pet and/or the care deemed necessary by this facility.

I understand that payment is due at the time of service.

In the event I fail to make payment in full for all services rendered by VetMobile for the treatment of my pet, on all unpaid balances, and/or in the event that my account becomes delinquent and is turned over for collections, I agree to pay 33.3% collection and/or attorney fees, plus legal court costs.

I understand that accounts not paid in full within 30 days of treatment will have an interest and billing fee added to the unpaid balance each month.
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Printed Name

First NameLast Name
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New Client Form

A quick little note: