New Client Information Form

New Client Form

Let us know how we can help you!
Client Full Name

First NameLast Name
Best Contact Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Drivers License Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Spouse/ Partner Name

First NameLast Name
Spouse/ Partner Cell:
Please enter a valid phone number.Format: (000) 000-0000.
Place of Employment
How did you hear about us?
Referred by:
Do we have permission to post pictures of your pet to our Facebook, Instagram, or Website?

Disclosures and Financial Agreements
*For your pet’s protection, we require all vaccinations or titers are current before hospitalization or surgery. If vaccines are not current your pet must receive them before staying in our facility, including but not limited to Rabies.

*Owners who abandon their pets will be prosecuted.

*Case information and/or photos may be used in teaching, continuing education, veterinary literature, and hospital promotions. Patient confidentiality will be maintained.
I do/do not authorize release of patient information for these purposes
Initial
I understand that payment is due at the time of service rendered. I also understand that if any balance remains unpaid and is sent to an outside agency for collection, I will be responsible in addition to the outstanding balance, for cost of collections,attorney’s fees, and interest at 18% per annum (15% per month) on the unpaidbalance.
Date

MonthDayYear
Date
Should be Empty:

New Client Form