Western Reserve Animal Clinic New Client Form

New Client Form

Welcome to our veterinary clinic! Please fill out the form to register as a new client.
Client Information
Have you been to our clinic before?*
Other Name Previously used at Western Reserve Animal Clinic

First NameLast Name
Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Home Phone Number
Please enter a valid phone number.
Cell Phone Number
Please enter a valid phone number.
Work Phone Number
Please enter a valid phone number.
Email Address
example@example.com
Date of Birth*

MonthDayYear
Date
Secondary Names on Account: Are there any other names that need to be added to the account that are authorized in the treatment decision making process and will provide financial responsibility?*
Secondary Name

First NameLast Name
Secondary Name Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Secondary Name Home Phone
Please enter a valid phone number.
Secondary Name Cell Phone
Please enter a valid phone number.
Secondary Name Email
example@example.com
Is the Secondary Name over the age of 18 years old
I was referred to the clinic by:
Pet Information
Pet's Name*
Type of Pet*

DogCatOther
Breed*
Age or Birthdate
Gender*

Male IntactMale NeuteredFemale IntactFemale SpayedUnknown
Color*
Medical History

Please provide any relevant medical history for your pet.
Vaccination Record

Cancelof
Medical Conditions
Reason for Visit
Previous Veterinarian where past medical records may be obtained if necessary.
I consent the release of my pet's medical information to Western Reserve Animal Clinic.
(enter name as signature)
Do you have another pet?*
Second Pet's Name
Type of Second Pet

DogCatOther
Breed of Second Pet
Age or Birthdate of Second Pet
Gender of Second Pet

Male IntactMale NeuteredFemale IntactFemale SpayedUnknown
Color of Second Pet
I prefer pet health reminder to be sent to by:

EmailPostcardBoth
Statement of Goodwill - I am 18 years of age or older and take on the financial responsibility of the care of this animal or any animal that is listed under my account at Western Reserve Animal Clinic
(enter name as signature)
I assume responsibility for all charges incurred in the care of this pet(s) that I have treated at Western Reserve Animal Clinic. I hereby authorize treatment as considered necessary. I also understand that these charges will be paid in full at the time of service.
(enter name as signature)
I understand that payment is due at the time of service and that accepted forms of payment are: Cash, Check, Care Credit, Scratchpay, Visa, Mastercard and Discover. I also understand that checks will not be held or post dated for payment.
(enter name as signature)
A copy of my driver's license has been given for identity purposes and also if I plan to write a check for payment*
(enter name as signature)
My driver's license number is
My driver's license expiration date is:

MonthDayYear
Date
I understand that me or my pet(s) may be photographed or filmed while at the premise and I give permission to the clinic, Pine Hollow Veterinary Services and all their affiliates to use and and all photos, video footage, written material and/or video streaming for promotional, sales, publicity and advertising purposes for all media including the internet.
(enter name as signature)
I understand that there is a $57 examination fee required when scheduling my pet’s appointment as a new client. This fee will be applied as a prepayment to my account and used at the time of the appointment. I also understand that if I cancel or fail to show up for the appointment, the examination fee is nonrefundable.
(enter name as signature)
My signature below is that I agree with all items with my name above in this documentture

Clear
Date

MonthDayYear
Date
Additional Comments
Clinic for this new client form:*

Western Reserve Animal Clinic
Should be Empty:

New Client Form

Client Information

Pet Information

Medical History