New Client Form

Baxter Creek Veterinary Clinic
Owner Name*
SpouseCoOwner Name
Address

Mailing Address

Street Address Line 2

CityStateZipState / Province

Postal / Zip Code
Physical Address if different from mailing address
Home Phone
Cell Phone*
Spouse/Co-Owner Phone
Email Address*
example@example.com
* To be used only for communications regarding your pet(s We will never share your email address with a third party.
How did you learn of our clinic
Please tell us if someone referred you so we can credit their account as a thank you
Pet's Name
Breed
Color
Birthdate

MonthDayYear
Date
Male/Female
In order to provide your pets with the best care possible we require a copy of the most recent vaccination information Who can we contact for this information
Payment is due at the time services are provided. If a prior payment arrangement has been made, the following terms apply. I agree to pay a finance charge of 1.25% per month (15% per year) on any balance not paid within 30 days of billing. If payment is not made as indicated, the account will be forwarded to our collection agency. All additional costs resulting from the collection agency, process servers, attorneys, court cost, etc. will be added to the bill and will be the responsibility of the client. A non-sufficient funds (NSF) check will be subject to an additional $30 fee. I, the undersigned, do hereby warrant and represent that the information contained herein is true and correct.
Signature of client responsible for pets*

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Date

MonthDayYear
Date
My Pet Is:

DogCatMy pet is neutered.My pet is NOT neutered.
Alternate Species of Pet
Microchip Status

My pet has a microchipMy pet does NOT have a microchip
Please list any current medications or health conditions:
Current Medications or health problems:
Should be Empty:

Baxter Creek Veterinary Clinic