New Client Form

Client Information *

Patient Information *

Are any of your pets micro-chipped? *

If yes, which pets?

Any allergies to vaccinations or medications? *

If yes, please list which pet and what allergies:

Is your pet on any special diet or medication? *

If yes, please list which pet and what diet/meds:

Do your pets have records at another vet clinic? *

If yes, please list the clinic name and location:

How did you hear about us? *

Drove By Google Yelp Our Website Social Media Referral

If you were referred, by whom:

PHOTO RELEASE WAIVER: I grant Belmont Veterinary Center, its representatives and employees, the right to take photographs of me and/or my pet in connection with the above-identified subject. I authorize Belmont Veterinary Center, its assigns and transferees, to copyright, use and publish the same in print and/or electronically. I agree that Belmont Veterinary Center may use photographs of me and/or my pet with or without my name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising, and web content. *

*ALL PAYMENTS ARE DUE AT THE TIME SERVICES ARE RENDERED*

We accept: cash, debit/credit (incl. American Express & Discover), checks and Care Credit

Signature *

Your signatiure signifies that you have read and acknowledge the above conditions of this hospital. Clear