Client Information

Client Name *

First

Last

Spouse/Other

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Primary Phone Number *

Is this number: *

Home
Cell
Work

May we text this number? *

Yes
No

Secondary Phone Number

Is this number:

Home
Cell
Work

May we text this number?

Yes
No

Email *

How Did You Hear About Us?

Occupation

Work Phone

Employer Name

Previous Vet

May we call for records?

Yes
No

Patient Information

Pet's Name *

Species *

Canine
Feline

Breed *

Sex

Male
Male - Neutered
Female
Female - Spayed

Date of Birth (Age) *

Does your pet have any special handling needs?

Do you have second pet?

Yes
No

Pet's Name *

Species *

Canine
Feline

Breed *

Sex *

Male
Male - Neutered
Female
Female - Spayed

Date of Birth (Age) *

Does your pet have any special handling needs?

Any Special Medical Needs/Alerts For Your Pets?

Social Media Release (pictures, no personal info)

Yes
No

PAYMENT & OTHER INFORMATION

Overnight Staff Policy: You have been made aware that we have trained technical staff on premises overnight but there is not a veterinary on site 24 hours/day. Should your pet need 24-hour veterinary supervision, we can facilitate a transfer upon your request.

Payment is REQUIRED at the time of service & a full deposit is also REQUIRED for any treatments/services

Forms of Payment: CASH, ALL MAJOR CREDIT CARDS (no checks are accepted)

Financial Aid Options: CareCredit, ScratchPay (please ask us for more information re: these 3rd party services)

By signing this form, I am agreeing that the above information is correct to the best of my knowledge. I also agree to be financially responsible for any treatment and/or fees related to services provided on any of my pets, today or for future appointments.

Signature *

Clear Signature

Date *

Small Animal New Patient Form