New Client Account Form

New Client Account Form

Please complete the information on this form to set up a new account at Cottonwood Animal Clinic. Please allow 2-5 business days for us to process your submission.
Primary Owner Information

Please bring a State issued picture ID such as a driver's license to your first appointment to complete the set up of your account.
Full Name

First NameLast Name
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Phone Type
Second Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Phone Type
Email Address (use the same email as on the app, if you want to use the PetsApp so that your account is correctly linked to your pets)
example@example.com
Co-Owner Information (if applicable)
Co-Owner Full Name

First NameLast Name
Co-Owner Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Co-Owner Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Phone Type
Co-Owner Email Address
example@example.com
Alternate Contact Person
Alternate Contact Name

First NameLast Name
Alternate Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Phone Type
Pet Information

This form allows up to two pets to be added to an account. If you have additional pets, please use the "Add a Pet to an Existing Account" form.
First Pet Name
First Pet Species
First Pet Breed
First Pet Color
First Pet Date of Birth (or estimate)

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
First Pet Gender
Microchip number
First Pet Previous Medical or Vaccine Records

Upload previous medical records or vaccine records. Multiple files are allowed.
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Second Pet Name
Second Pet Species
Second Pet Breed
Second Pet Color
Second Pet Date of Birth (or estimate)

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Second Pet Gender
Microchip number
Second Pet Previous Medical or Vaccine Records

Upload previous medical records or vaccine records. Multiple files are allowed.
Cancelof
Financial Responsibility Agreement
I acknowledge that I am financially responsible for all services provided and payment is due at the time services are rendered.
Signature of Financially Responsible Party
Should be Empty:

New Client Account Form

Primary Owner Information

Co-Owner Information (if applicable)

Alternate Contact Person

Pet Information

Financial Responsibility Agreement