New Client/Patient Form

New Client/Patient Form

Please fill out each area to your best ability.
Primary Owner's Name:

First NameLast Name
Address

Address

Street Address Line 2

CityState

Zip Code
Primary Phone #
Format: (000) 000-0000.
Work phone #
Format: (000) 000-0000.
Additional phone #
Format: (000) 000-0000.
Email address
example@example.com
Secondary Owner

Primary Owner gives permission for the secondary owner to make medical decisions.
Name

First NameLast Name
Relationship to primary owner:

Other
Secondary Owner's Primary Phone #
Format: (000) 000-0000.
Secondary Owner's Additional Phone #
Format: (000) 000-0000.
How did you hear about us? (Please check all that apply)

Other
Pet Information

Please fill out each area to your best ability.
Name
Breed
If a mixed breed, please write down mixed.
Date of birth/estimated age:
Coat Color
Species
Sex:
Previous clinic and where veterinary records can be obtained:
Records and Social Media Release:

Please sign in each section where you are allowing us to either receive medical records and/or permission to post to social media. Do not sign if you are not giving permission.
I allow Valley Animal Clinic to call the above veterinary clinic to retrieve my pet's prior vaccine/medical records.
FOR THOSE WHO HAVE PET INSURANCE OR ARE PLANNING ON GETTING PET INSURANCE: I allow Valley Animal Clinic to release records to my Pet Insurance Company.
I allow Valley Animal Clinic permission to take photographs and/or video of my pet(s), that may be posted to Valley Animal Clinic's Facebook page.
What is the reason for your upcoming veterinary appointment?
I hereby authorize the veterinarian(s) and staff of Valley Animal Clinic to administer needed medical and/or surgical treatment for my pets. I understand that medical estimates will be provided upon my request. I assume financial responsibility for all charges incurred for the care of my pets. I also understand that direct payment is due at time of service and that a deposit may be required for extensive treatments. If there are unpaid fees after 60 days your account will be charged $25 for a billing fee and may incur additional fees if left unpaid past 60 days. If payment is not made after 90 days, the account will be sent to CBM collections agency and a 25% fee of the total owed will be added to the account.
Client Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Owner Provided Records

If you are providing records to us and do NOT need us to call your prior veterinary clinic, please upload below.
File Upload

Cancelof
Should be Empty:

New Client/Patient Form

Secondary Owner

Pet Information

Records and Social Media Release:

Owner Provided Records