New Client Form 2

First Name*

Last Name*

Address

City

State

Zip Code

Primary Phone*

Email*

Best way to reach you?

PhoneTextEmail

Your Pet(s) Spouse/Co Owner

Phone

Your Pet(s) Name

Breed

Your Pet(s) Date of Birth

Color

Sex (Sprayed or neutered)

Any chronic diseases/illnesses that we should know about *

Is your pet(s) under medications? *

How did you hear about us? *

Family/FriendInternet SearchFacebookOther (Please indicate below)

Is anyone in your home (human or pet) allergic to peanut butter or have any other allergies? *

I, *

the undersigned, am the owner or agent for the owner of the animal(s) described, and I
have the full and exclusive authority to execute this consent.

I certify that I am 18 years of age or older.I give permission to doctors, staff, authorized agents, or representatives of this hospital to examine, prescribe for, and treat my pets.I consent to video and audio recording for the purpose of enhancing the quality of care and ensuring the safety and well-being of both myself and the veterinary staff.I agree to pay for all services rendered and medications, goods, and supplies when purchased.I understand that all fees are due at the time services are rendered and the hospital accepts cash, check, and all major credit cards.I understand that a deposit may be required for surgical or medical treatment.I release this hospital from any and all liabilities.

By my signature below, I hereby acknowledge that I agree to all of the above and acknowledge the receipt of a copy of
this agreement upon request. *

Owner/Agent Name

Date

Please fill out this form as completely
and accurately as possible so we can get to
know you and your pet before your visit.

We require a reservation deposit of $64.00 for new clients, which will be applied toward the cost of the exam. This deposit is refundable if the appointment is canceled at least 48 hours in advance.

About Us

Services

New Client Form 2

Please fill out this form as completely and accurately as possible so we can get to know you and your pet before your visit.

We require a reservation deposit of $64.00 for new clients, which will be applied toward the cost of the exam. This deposit is refundable if the appointment is canceled at least 48 hours in advance.

Please fill out this form as completely
and accurately as possible so we can get to
know you and your pet before your visit.