<h1>New Client Form</h1>

Please fill out this form as completely and accurately as possible so we can get to know you and your pets before your visit.

Name*

First NameLast Name

Email*

example@example.com

Primary Phone*

Secondary Phone*

Address*

Street Address

Street Address Line 2

CityState

Zip Code

Who else is authorized to make decisions about your pet's healthcare?*

First NameLast Name

Phone

How did you find out about our hospital? If you were referred by someone, who should we thank?*

Pet's Name*

Species (dog, cat, etc.)*

Breed*

Age/Date of Birth*

Sex*

MaleNeutered MaleFemaleSpayed Female

Does your pet have a microchip identification?*

YesNo

What is the microchip number?

Do you have a second pet?*

YesNo

Pet's Name #2*

Species (dog, cat, etc.)*

Breed*

Age/Date of Birth*

Sex*

MaleNeutered MaleFemaleSpayed Female

Does your pet have a microchip identification?*

YesNo

What is the microchip number?

Do you have a third pet?*

YesNo

Pet's Name #3*

Species (dog, cat, etc.)*

Breed*

Age/Date of Birth*

Sex*

MaleNeutered MaleFemaleSpayed Female

Does your pet have a microchip identification?*

YesNo

What is the microchip number?

Do you have a fourth pet?*

YesNo

Pet's Name #4*

Species (dog, cat, etc.)*

Breed*

Age/Date of Birth*

Sex*

MaleNeutered MaleFemaleSpayed Female

Does your pet have a microchip identification?*

YesNo

What is the microchip number?

Do you have a fifth pet?*

YesNo

Pet's Name #5*

Species (dog, cat, etc.)*

Breed*

Age/Date of Birth*

Sex*

MaleNeutered MaleFemaleSpayed Female

Does your pet have a microchip identification?*

YesNo

What is the microchip number?

Payment is due in full at the time that services are performed. If being admitted into the hospital, we cannot begin the care of your Pet until you have confirmed your desire to do so by 1) signing the client consent & estimate form, and 2) leaving an initial deposit of 50% of the upper end of the estimate. This is the only way that we have of knowing for certain that you want us to proceed with the care of your Pet. We accept cash, Visa, MasterCard, Discover, and CareCredit payments. We neither extend credit, nor bill for services. All open invoices are sent to collections after 45 days unless prior arrangements are made.*

I have read and accept the financial policy.