ST. FRANCIS PET HOSPITAL
3294 US Hwy. 93 | Darby, MT 59829 | (406) 821-0000
New Client Intake Form
Please complete the following form as thoroughly as possible prior to your appointment at St. Francis Pet Hospital.
Client ID: ______
Clinic office use only
Pet Owner's Name
*
First Name
Last Name
Spouse/Partner's Name
First Name
Last Name
Mailing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Street Address (if different than Mailing Address)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Phone Number
*
Secondary Phone Number
Primary E-mail
*
example@example.com
Owner ID
*
Last 4 digits of social security #
Driver's License # - If you will be using checks for payment at any time, we will need your driver's license number. If you choose not to fill in the information, only cash or credit cards will be accepted as payment.
How did you hear about us?
*
Please Select
Newspaper
Internet
Drive by
Friend/Family
Keep It Local
Church Bulletin
Other
Please Specify:
*
Prior/Current Veterinarian Clinic:
IMPORTANT: Please contact your past or current veterinary clinic to have them email all records to sfphdarby@gmail.com prior to your appointment This way, we can consider your pet's history for best service. If necessary, you may also bring in hard copy records at the time of your appointment.
Please list all pets below:
Pet Name
Breed
Age or DOB
Sex
Spayed/Neutered?
Date of Last Vaccines
1
2
3
4
5
DUE TO CIRCUMSTANCES BEYOND OUR CONTROL, WE CANNOT, & DO NOT, EXTEND CREDIT.
I (owner) agree to pay for all collection fees, attorney fees, and interest charges if, at the discretion of management, I am sent to collections for unpaid dues. I understand that an exam fee will be charged automatically if more than (2) consecutive appointments are missed without cancellation made at least 24 hours in advance. I understand that this fee may also be applied at the discretion of St. Francis Pet Hospital, should no-show tendencies be persistent.
Owner's Birth Date
-
Month
-
Day
Year
Date
Owner Signature
Today's Date
-
Month
-
Day
Year
Date
Please verify that you are human
*
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Should be Empty: