Owner Contact Information

Your Name *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

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Primary Phone *

Email *

Alternative Phone *

Work # (in case of emergency):

How were you referred to us?: *

Personal Recommendation: Who should we thank?

Would you like to add your spouse or a co-owner? *

Yes
No

Spouse or Co-Owner Contact Information

Co-Owner name *

Address

Address Line 1

Address Line 2

City

State

Zip Code

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Email *

Work # (in case of emergency):

Name and phone number of anyone else authorized to order treatment or obtain patient information:

Pet/s Information

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Pet Name *

Type of Pet

Please specify the type of pet *

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Breed *

Date of Birth or Age *

Color *

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Sex *

If spayed/neutered, at what age?

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What is your pet's diet? *

What vaccines has your dog received?

What vaccines has your cat received?

FVRCP
Rabies
Leukemia

What date did your pet receive these vaccinations *

Reason for visit *

Any previous serious illnesses or surgeries? *

Assessing Your Pet’s Health Risk

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Treatment Authorization and Information

I HAVE READ THE PREVIOUS STATEMENT AND AGREE TO THE TERMS.

We will gladly prepare a written estimate of service fees if you desire (please ask your doctor or receptionist). All professional fees are due at the time services are rendered. We accept cash, check, and major credit cards. In case of extensive medical or surgical procedures, we do require a deposit. We offer Care Credit financing for qualified clients, please ask a receptionist for details. Returned checks are subject to a $20 returned check fee. All balances are subject to a monthly finance charge. If it becomes necessary to send your account to a collection agency, you are responsible for all collection fees incurred. I am the owner or an authorized agent for the owner of the above pet and have the authority to execute this agreement. I authorize the Veterinary Clinic to examine and treat the above pet. I affirm that the above information is accurate and correct. I agree to defend, indemnify, and hold the Veterinary Practice harmless for any claims and injuries that I may have or suffer that arise as a result of, or are caused by, my pet.

Please type your name to agree *

Today's Date *

New Client Form

New Client Form

Owner Contact Information

Spouse or Co-Owner Contact Information

Pet/s Information

Assessing Your Pet’s Health Risk

Ready To Make An Appointment?

Questions?

Location

Contact Information

Hours