New Client Information Form

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New Client Information Form

Thank you for giving us the opportunity to care for your pet. Please help us better meet your needs by taking a few moments to fill out this information sheet.

Message Sent

First Name

Last Name

Address

Home Phone

Work Phone

Cell Phone

Email Address

Employer's Name & Address

Spouse/Other Name

Spouse/Other Cell Phone

Spouse/Other Employer Name & Phone

Emergency Contact Name

Emergency Contact Phone

Name of Previous/Current Veterinarian

How did you hear about us?

Do you have Pet Health Insurance?

We will gladly prepare a written estimate if you so desire. Please ask a receptionist or doctor. Professional fees are due at time services are rendered.

To help prevent the spread of infectious diseases, ALL hospitalized animals must be current on all vaccinations. DUE TO STATE LAW AND INSURANCE REQUIREMENTS, ALL DOGS AND CATS MUST BE CURRENT ON RABIES VACCINATION. 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) I present for care. 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 understand that a service fee of $50.00 will be assessed for each non-sufficient funds check and/or certified letter that must be sent. 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 begin Abandoned Animal Proceedings as outlined by State Law.

I have read and agree to the terms and conditions.