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Home New Client Form

New Client Form

Your appointment is booked! You will receive an email confirmation shortly. Please submit this New Client Form at least 48 hours before your scheduled appointment. We look forward to seeing you and your pets soon!

"*" indicates required fields

Welcome to Our Practice!

First Name*

Last Name*

Phone*

Address*

Street Address

Address Line 2

City

State

ZIP Code

Spouse/Partner Name

Spouse/Partner Phone

Primary e-mail address for communications*

We use email for Pet Portal access, newsletters, reminders, and client education. We never sell email addresses.

Patient Information

Pet's Name*

Breed*

DOB/Age*

Color*

Sex*

Male

Male Neutered

Female

Female Spayed

Do you want to add a second pet?*

Yes

Pet's Name*

Breed*

DOB/Age*

Color*

Sex*

Male

Male Neutered

Female

Female Spayed

Do you want to add a third pet?*

Yes

Pet's Name*

Breed*

DOB/Age*

Color*

Sex*

Male

Male Neutered

Female

Female Spayed

Please email a copy of any previous pet medical records, at least 48 hours before your appointment to [email protected]

PROFESSIONAL FEES ARE DUE AT THE TIME SERVICES ARE RENDERED

We accept cash, local checks, Visa, MasterCard, Discover, American Express, and Care Credit.

Fee Agreement

I agree to be responsible for authorizing procedures and/or paying for services. Any unpaid balance will accrue finance charges monthly and court fees if sent to collections

Statement of Ownership

Ownership Agreement

I certify that I am the true owner and/or agent of the above animal(s) and have authorization to consent to treatment if and when it is needed. I understand that by signing this document, I agree to the above terms of service.

Signature*

Date*

MM slash DD slash YYYY

Name

This field is for validation purposes and should be left unchanged.