New Client Information

New Client Information

This form is designed to quickly gather the needed information and get you added to our scheduling system! If you are already an established client, you do not need to fill this form out again; you may text 256-614-5444 with your requests.
**You will be contacted directly for appointment confirmation! Please allow us time to get back with you with available appointment times!**

Note: Under most circumstances, we are unable to offer same day/next day appointments, due to the overwhelming level of interest in our services.
Owner Name

First NameLast Name
Spouse/Other Owner, if applicable

First NameLast Name
Cell Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Directions to your location if your residence can be difficult to find, or any other pertinent information about your location ("Park at Driveway entrance", gate code information, etc)
Primary Pet Name (Required for Apt Scheduling)*

Pet NamePet Species, Breed, Age. Sex
Additional Pet(s) Name

Pet NamePet Species & Breed
Additional Pet(s) Name

Pet NamePet Species & Breed
What service(s) are you needing? If you are having an emergency and/or it is outside of our business hours, PLEASE CALL MADISON VET ER AT 256-434-5290 OR FLORENCE ANIMAL ER AT 256-740-4800 AS SOON AS POSSIBLE. You may also list any additional pets here and describe what services they need.*
Please Confirm your understanding:

I understand that this is only a new client appointment request and that if I haven't heard back from ERVS within 48 hours (or 72 hours on weekends), I should contact ERVS directly at (256) 614-5444.I understand that there is a $25 cancellation fee per pet scheduled if an appointment is cancelled within 24 hours of their appointment. A $50 fee per pet scheduled will occur on all same-day cancellations or "no show/unconfirmed" appointments. This fee will have to be paid in full before I am allowed to reschedule.I understand that charging services/product on my account is not allowed. Payment is due in full at the time of the visit. We accept cash, card or check (with DL number). We do not accept care credit at this time.
Should be Empty:

New Client Information

**You will be contacted directly for appointment confirmation! Please allow us time to get back with you with available appointment times!**

You will be contacted directly for appointment confirmation! Please allow us time to get back with you with available appointment times!