New Client Form

    Thank you for giving us the opportunity for your pet. Please help us to better meet your needs by taking a few moments to fill out this information form. There are times of emergency when we must be able to reach the owners immediately, which is why we need so many ways to contact you. Please take your time to give us as much information as possible so we may reach you during emergencies

    Required Fields in Red

    Owner:

    Address:

    Apartment #:

    City:

    State:

    Zip:

    County:

    Email Address:

    Home Phone:

    Work Phone:

    Cell Phone:

    Spouse/Other:

    Cell Phone:

    Emergency Contact and Phone:

    Which form of communication do you prefer (Appt & Vaccine Reminders)?

    Phone, Email or Text?

    *** It is extremely important that we have vaccination information on all of your pets. Please provide the name and contact information for your previous or current veterinarian so that we can obtain this information. Please give the receptionist any medical records you have with you today so that we can update your pet’s medical file.

    How did you hear of our hospital?

    If from other advertising or if there's someone we may thank, please state:

    Pet #1

    Pet's Name

    Species (Dog, Cat, etc...)

    Breed

    Description (Color and Markings)

    Age or Date of Birth (Approximate)

    Sex

    Spayed or Neutered

    Diet (Name of your pet’s food)

    Medications used

    Flea products used

    Heartworm prevention used

    Hours spent outside each day

    Pet #2

    Pet's Name

    Species (Dog, Cat, etc...)

    Breed

    Description (Color and Markings)

    Age or Date of Birth (Approximate)

    Sex

    Spayed or Neutered

    Diet (Name of your pet’s food)

    Medications used

    Flea products used

    Heartworm prevention used

    Hours spent outside each day

    Pet #3

    Pet's Name

    Species (Dog, Cat, etc...)

    Breed

    Description (Color and Markings)

    Age or Date of Birth (Approximate)

    Sex

    Spayed or Neutered

    Diet (Name of your pet’s food)

    Medications used

    Flea products used

    Heartworm prevention used

    Hours spent outside each day

    If any of the above pet(s) are on medication, please list below:

    To help prevent the spread of infectious diseases, ALL hospitalized and boarded animals must be current on all vaccinations. DUE TO STATE LAW AND INSURANCE REQUIREMENTS, ALL DOGS & CATS MUST BE CURRENT ON RABIES VACCINATIONS. Vaccination can be updated at the time of your appointment if it is not current.

    I understand every effort will be made to achieve a successful outcome and to provide for all possible safety in hospital care and handling. I hereby authorize this hospital to receive, prescribe for, treat or perform surgery upon the pet(s) listed in this form and additional pets I present. Furthermore, I agree to pay fees for services rendered at the time the pet is discharged from the hospital or the service is otherwise terminated. I agree to pay for the reasonable costs of collection in the event that collection efforts become necessary. I understand that a service fee of $20.00 will be assessed for each non-sufficient fund check and/or certified letter that must be sent. All accounts unpaid after 30 days receive a $5.00 Billing Charge each month and a late charge, computed at a periodic rate of 1.50% per month, which is an annual percentage rate of 18.00%, with a minimum monthly charge of $1.00. I understand that veterinary service is provided during nighttime hours as necessary in the judgment of the veterinarian in charge. Continuous presence of qualified personnel may not be provided. If I neglect to pick up my pet within 5 days of the discharge date and do not notify you within that time period, you may assume that the pet is abandoned and are hereby authorized to dispose of the pet as you deem best and/or necessary.

    Digital Signature

    Date