New Client Information Form
Client Information
Owner Name
*
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Place Of Employment
Business Phone
Please enter a valid phone number.
Home Phone
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
E-mail
*
example@example.com
Spouse’s Name
Spouse's Phone
Please enter a valid phone number.
Preferred Method of Contact
Text
Phone Call
Email
Personal Recommendation - Whom May We Thank? (Name)
Pet Information
Pet #1 Name
*
Breed
Color
Species
Dog
Cat
Exotic
Sex
Female
Spayed Female
Male
Neutered Male
Date Of Birth
Do you have another pet to add?
Yes
No
Pet #2 Name
*
Breed
Color
Species
Dog
Cat
Exotic
Sex
Female
Spayed Female
Male
Neutered Male
Date Of Birth
Do you have another pet to add?
Yes
No
Pet #3 Name
*
Breed
Color
Species
Dog
Cat
Exotic
Sex
Female
Spayed Female
Male
Neutered Male
Date Of Birth
Please let us know if you, your family members, or your pet are allergic to peanuts.
Yes
No
Can we give vaccine information to your groomer, pet daycare, rescue, or boarding facility?
Yes
No
Photo Permission
I grant Prairie Lane Veterinary Hospital, its representative and employees the right to take photographs of me and/or my pet, and to copyright, use and publish the same in print and/or electronically. I agree that Prairie Lane Veterinary Hospital may use such 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.
*
The above may take photos of me and/or my pet.
The above may NOT take photos of me and/or my pet.
Payment Options
You can choose from:
Cash
Check
Visa®
MasterCard®
American Express®
Discover Card®
Convenient Monthly Payment Plans¹ from Care Credit® (¹Subject to credit approval)
Allow you to begin treatment today and pay overtime.
Available for any treatment amount
Can be used repeatedly - for your entire family - without having to reapply¹
See CareCredit.com for more information.
Additional Policy Information
A $50 fee will be charged for all returned checks. For clients with pet insurance, we are happy to provide you with the necessary documentation to submit a claim to your insurance carrier.If you have any questions, please do not hesitate to ask. We are here to provide the best veterinary care available for your pet.
Financial Policy Acceptance
I understand that all professional fees are due at the time services are rendered. By signing below, I assume responsibility for all charges incurred in the care of my animal(s).
Signature
Date
-
Month
-
Day
Year
Date
Submit
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