New Client Form

Pet owner's first name: *

Pet owner's last name: *

Spouse/Co-owner's name

Mailing Address: *

City: *

State: *

Zip: *

Preferred Phone Number: *

Other Phone:

Previous Veterinarian

Email: *

Your email address is important to not only receive copies of lab work and other documents for your pet but to also be kept up to date regarding critical changes to policies and changes that may affect you and your pet during these unprecedented times.

Please tell us about your pet(s). For our records, we ask that you list every pet, even if they are not being seen today.

Pet #1

Pet #1 Name: *

Species: *

Breed: *

Date of Birth/Age: *

Color: *

Pet #1 Sex: *MaleFemale

Pet #1 Spayed/Neutered: *YesNo

Any current history of problems we should be aware of (behavioral – fear biter, aggressive; clinical – chronic skin problems, diabetes, etc). If yes, please provide information below.

Please upload the most recent (within the year) medical records for pet #1

No file chosen

Pet #2 Name: *

Species: *

Breed: *

Date of Birth/Age: *

Color: *

Pet #2 Sex: *MaleFemale

Pet #2 Spayed/Neutered: *YesNo

Any current history of problems we should be aware of (behavioral – fear biter, aggressive; clinical – chronic skin problems, diabetes, etc). If yes, please provide information below.

Please upload the most recent (within the year) medical records for pet #2

No file chosen

APPOINTMENT REQUEST

Pet's Name *

Desired Appointment Date: *

Desired Time: *

Reason for Your Appointment or Your Question: *

Please bring the information with you for any additional pets you wish to add

Professional fees are due in full at the time services are provided.

We offer Care Credit services as well as payment plans (Scratch Pay) for those wishing to apply. Please let us know if you would like an application for either of these programs. The link to the forms are also provided on our website.

We accept cash and the following credit cards for your convenience: Visa, MasterCard, and American Express.

Please be aware that under no circumstance do we share any of this information with companies not working with us directly on your behalf.

May we share photos of your pet on our website or Facebook page?YesNo

I understand that I will be required to make a non-refundable deposit to schedule an appointment. This deposit will be applied to my services. Two business days (hospital business hours only) notice is required to reschedule this appointment and avoid loss of deposit. The appointment can only be rescheduled one time without loss of deposit. Thank you for your understanding and cooperation.

Click Here to Sign

By clicking accept and sign, I agree that this signature is the electronic representative of my personal signature for use on all documents including legally binding documents in this office – in just the same way as a pen-and-paper signature. *

*Accept and Sign

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