New Client Registration Form

Co-Owner Name (first & last):

Co-Owner Phone Number:

Patient Information:

Pet's Name

Species

Sex

Female Intact

Female Spayed

Male Intact

Male Neutered

Color

Breed

Age / DOB

Is your pet up to date with their vaccines?

Yes

Does your pet have any allergies? If so, please list:

Is your pet on any current medication or have a medical condition? If so, please explain:

I understand that my pet’s picture may be used on social media sites.

YES, you can use my pet's photo on social media.

NO, do not use my pet's photo on social media.

General Information

Would you like us to request any records from your previous veterinarian?, If so, please provide the clinic name/and or phone number:

Payment Information

Payment is due when services are rendered.

Please provide your card information if you would like us to keep it on file:

Card Number:
Expiration Date:
CVV:
Billing Zip Code:

How did you hear about us?

Internet Search

Drive By

Client Referral

Other

If you were referred by a client, what is their name?

We charge $82.00 for an exam if any treatment is needed day of, we will provide you with an estimate. We do require a deposit the day of the appointment. This will go towards your first visit and is non-refundable. You will need to check in 10 minutes before your appointment, if you arrive 10 minutes late, it will be considered a missed appointment and your pet will not be seen and you will need to reschedule the appointment.

I assume responsibility for all charges incurred in the care of this patient. I understand that these charges will be paid at the time of release and that a deposit may be required for surgery or hospitalized treatment.

Please type your name below to serve as acknowledgment of the above-mentioned statement.*

New Client Registration Form

Co-Owner Name (first & last):

Co-Owner Phone Number:

Patient Information:

Pet's Name

Species

Sex

Color

Breed

Age / DOB

Is your pet up to date with their vaccines?

Does your pet have any allergies? If so, please list:

Is your pet on any current medication or have a medical condition? If so, please explain:

I understand that my pet’s picture may be used on social media sites.

General Information

Would you like us to request any records from your previous veterinarian?, If so, please provide the clinic name/and or phone number:

Payment Information Payment is due when services are rendered.

Please provide your card information if you would like us to keep it on file:

How did you hear about us?

If you were referred by a client, what is their name?

Payment Information

Payment is due when services are rendered.