New Client Form
We know that your pet’s health is important and we thank you for trusting us to care for them. To help us provide the best care possible, please take a few moments to fill out this form.
Owner/Responsible Person
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Employer
Work Number
Date of Birth
-
Month
-
Day
Year
Driver's License Number
May we text you?
*
Yes
No
How did you hear about our clinic? Please check all that apply.
*
Road Sign
Internet/Google
Website
Friend/Family Member
If you were referred by someone, who should we thank?
What day is your appointment scheduled for?
-
Month
-
Day
Year
Date
Would you like to add an authorized person to make decisions on your pet's health/financial?
YES
NO
Secondary Contact Name
First Name
Last Name
Secondary Phone Number
Please enter a valid phone number.
Secondary Email
example@example.com
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Pet's Name
*
Species (dog, cat, etc.)
*
Breed
*
Color
*
Age/Date of Birth
*
Sex
*
Male
Neutered Male
Female
Spayed Female
Does your pet have a history at another veterinary clinic?
*
Yes, please contact my previous veterinarian
Yes, I will contact my previous veterinarian
Yes, I can upload them now
No
Please list previous veterinarian and contact
File Upload
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Would you like to add another pet?
YES
NO
Pet's Name
Species (dog, cat, etc.)
Breed
Color
Age/Date of Birth
Sex
*
Male
Neutered Male
Female
Spayed Female
Does your pet have a history at another veterinary clinic?
Yes, please contact my previous veterinarian
Yes, I will contact my previous veterinarian
Yes, I can upload them now
No
Please list previous veterinarian and contact
File Upload
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Back
Next
Patient Medical information
List any serious illness or surgeries for any of the pets (please identify the pet upon listing information)
List any allergies to vaccines or medications for any of the pets (please identify the pet upon listing information)
Special diet or medication (please identify the pet upon listing information)
We pledge to do our very best to care for your pet’s health needs. In return we ask that you accept the responsibility for charges incurred in the treatment of your pet and accept that payment is due when services are rendered. There is a 60% deposit required at time of admission for all hospitalized/emergency patients. Please feel free to ask for an ESTIMATE prior to providing services. For your convenience we accept MasterCard, VISA, American Express, Discover, Care Credit or Cash.
*
Print your name
Treatment/Payment Authorization: I understand every effort will be made to achieve a successful outcome and provisions will be made for safe in-hospital care and handling. I certify that I am 18 years of age or older and assume responsibility for all charges incurred. I understand that charges are due at the time of service unless prior arrangements have been made. I agree that should my account become delinquent, I will be responsible for all collection costs, including but not limited to the outstanding balance, interest, attorney fees, court costs and collection agency fees. I hereby authorize Monroe Veterinary Clinic to treat my pet(s) and furthermore understand that unforeseeable adverse reactions to treatments are always possible and authorize treatment necessary should any reaction occur.
*
Print your name
Social Media: I grant permission for Monroe Veterinary Clinic to use photos for the purpose of social media post (Facebook, Instagram, YouTube and other sites).
*
Use the image only
Use the image and first name of pet
I do NOT give permission for the use of photos of my pet(s)
Full Name As Signature
*
First Name
Last Name
Today's Date
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: