Tenafly/Overpeck - New Client Form

New Client Form
Which hospital are you bringing your pet to?*

Tenafly Veterinary CenterOverpeck Creek Animal Hospital
Owner Name*

First NameLast Name
Co-Owner Name

First NameLast Name
Owner Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Owner Phone Number*
Please enter a valid phone number.
Co-Owner Phone Number
Please enter a valid phone number.
Owner Email Address*
example@example.com
Co-Owner Email Address
example@example.com
How would you prefer to receive reminders?*

EmailTextBoth Are Fine
Emergency Contact*

First NameLast Name
Emergency Contact Phone Number*
Please enter a valid phone number.
How did you hear about us?*

GoogleYelpWalk ByFacebookInstagramShelter/RescueClientEmployeeOther Hospital/DoctorOther
If Shelter/Rescue/Client/Employee/Other Hospital/Doctor, who can we thank for the referral?*
Pet Information
Pet #1
Pet Name*
Pet Birthdate or Age (If Known)
Color/Description*
Species*

DogCat
Breed*
Sex*

MaleFemale
Spayed/Neutered*

YesNo
Microchipped?*

YesNo
Do you have an appointment for your pet? If yes, please provide your scheduled date and time.
What is the reason for your visit?*
Please list any medical conditions your pet has:
Do you have another pet to add?

YesNo
Pet #2
Pet Name*
Pet Birthdate or Age (If Know)
Color/Description*
Species*

DogCat
Breed*
Sex*

MaleFemale
Spayed/Neutered*

YesNo
Microchipped*

YesNo
Do you have an appointment for your pet? If yes, please provide your scheduled date and time.
What is the reason for your visit?*
Please list any medical conditions your pet has:
Do you have another pet to add?*

YesNo
Pet #3
Pet Name*
Pet Birthdate or Age (If Know)
Color/Description*
Species*

DogCat
Breed*
Sex*

MaleFemale
Spayed/Neutered*

YesNo
Microchipped*

YesNo
Do you have an appointment for your pet? If yes, please provide your scheduled date and time.
What is the reason for your visit?*
Please list any medical conditions your pet has:
Do you have another pet to add?*

YesNo
Pet #4
Pet Name*
Pet Birthdate or Age (If Know)
Color/Description*
Species*

DogCat
Breed*
Sex*

MaleFemale
Spayed/Neutered*

YesNo
Microchipped*

YesNo
Do you have an appointment for your pet? If yes, please provide your scheduled date and time.
What is the reason for your visit?*
Please list any medical conditions your pet has:
If you have medical records for your pet(s), please upload them here. These records help us provide the best care for your pet(s) by ensuring we have accurate information about their health history, vaccinations, and any ongoing treatments.

Cancelof
Authorization and Payment Policy
I hereby authorize the veterinarian to examine, prescribe or treat the above described pet(s). I assume full responsibility for all charges incurred in the care of this animal. I also understand that these charges must be paid in full at the time of release and minimum deposit of 80% is required should my pet need to be admitted into the hospital for treatment or surgical procedure in order to provide the best care. NO CHECKS PLEASE. Payments are expected in full when services are rendered, we DO NOT BILL. Any balance remaining on the account over 30 days will result in a monthly service charge of $10.00 minimum or 1.75% service fee of the unpaid balance, whichever is greater, will be added to the outstanding balance. The service fee is not intended to be an interest charge, but reimbursement for servicing the account. If you fail to pay any sum due and this matter is placed with a collection agency, or an attorney for collections, you shall be obligated and agree to pay for all costs and expenses incurred (including a collection fee, plus all attorney's fees, court costs and other expenses through judgment and post-judgment), which shall be payable whether or not an action or proceeding is commenced or prosecuted to judgment. By signing below, I hereby state that I am the owner or authorized agent of the above described animal. I have read the above terms and conditions and agree to adhere to this agreement.

If you have any questions or concerns regarding payment, please feel free to contact us before your appointment. Thank you for your understanding and cooperation.
Social Media Release
I hereby grant Tenafly Veterinary Center/Overpeck Creek Animal Hospital permission to use my testimonial or likeness in a photograph, video, or other digital media ("Photo") in any and all of its publications, including web-based publications, without payment or other consideration, for purposes of advertising the hospital staff or services.

I understand and agree that all photos will become the property of the Tenafly Veterinary Center/Overpeck Creek Animal Hospital and will not be returned.

I hereby irrevocably authorize Tenafly Veterinary Center/Overpeck Creek Animal Hospital to edit, alter, copy, exhibit, publish, or distribute any testimonial and Photo for any lawful purpose. In addition, I waive any right to inspect or approve the finished product wherein my testimonial or likeness appears. Additionally, I waive any right to royalties or other compensation arising or related to the use of the testimonial or Photo.

I hereby hold harmless, release, and forever discharge the Tenafly Veterinary Center/Overpeck Creek Animal Hospital from all claims, demands, and causes of action which I, my heirs, representatives, executors, administrators, or any other persons acting on my behalf or on behalf of my estate have or may have by reason of this authorization.
I HAVE READ AND UNDERSTAND THE ABOVE PHOTO RELEASE. I AFFIRM THAT I AM AT LEAST 18 YEARS OF AGE, OR, IF I AM UNDER 18 YEARS OF AGE, I HAVE OBTAINED THE REQUIRED CONSENT OF MY PARENT/GUARDIAN AS EVIDENCED BY THEIR SIGNATURE BELOW.*

I agreeI do NOT agree
(Owner) Parent or Guardian Name*

First NameLast Name
(Owner) Parent or Guardian Signature*

Clear
Today's Date*

MonthDayYear
Date
Should be Empty:

New Client Form

Pet Information

Pet #1

Pet #2

Pet #3

Pet #4

Authorization and Payment Policy

Social Media Release