Animal Health Care Denver New Client Form

Name/Owner

First NameLast Name

Co-Owner

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Owner Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Owner Cell Number

Please enter a valid phone number.Format: (000) 000-0000.

Owner Email

example@example.com

Owner Work Number

Please enter a valid phone number.Format: (000) 000-0000.

Co-Owner Number

Please enter a valid phone number.Format: (000) 000-0000.

Co-Owner Email

example@example.com

How Did You Hear About Us?

Pet Name #1

Breed

Species

Birthdate/Age

Coloring

Gender

Spayed/Neutered

Microchipped?

Tag Number#

Do you have another pet with you today?

Pet Name #2

Breed

Species

Birthdate/Age

Coloring

Gender

Spayed/Neutered

Microchipped?

Tag Number#

Previous Veterinarian (Name & Phone Number) - So we may obtain medical history.

Can we share pictures of your pet on our social media platforms?

PAYMENT IS DUE IN FULL AT TIME SERVICES ARE RENDERED

I understand that if I do not pay this account as agreed, the account is subject to costs of collection, attorney fees, and including interest (any balance that is carried over a period of 30 days will accrue a monthly finance charge of 1.5% or 18% per annum). Returned check fee is $40. I understand that the hospital staff will provide an estimate of current and anticipated charges any time I request one. I am requesting that veterinary care be provided for pets presented by me or my agents. I understand that I am financially responsible for all services provided. For hospitalized cases, a deposit may be required in advance. By submitting this form I agree to the payment terms above. WE ACCEPT THE FOLLOWING: Cash, Check, CareCredit®, Scratchpay, Master Card, Visa, Discover, & American Express.

Signature

Date

New Client Form

Client Information

Current Pet Information

Payment Policy