Online Form

NEW CLIENT FORM

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Online Form

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

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NEW CLIENT FORM

Thank you for giving us the opportunity to care for your pet. Please help us to better meet your needs by taking a few moments to fill out this information sheet. State and Federal Law requires you must be 18 to complete this form.

Owner's Name *

Spouse/Other

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone Number

Alternate Number

Work Phone *

Email address *

Spouse/Other Phone

Emergency Contacts

Name/Number

Pet Information

Pet's Name *

Breed *

Color *

Age *

Sex *

Male
Female

Spayed/Neutered? *

Second Pet's Name *

Breed *

Color *

Age *

Sex *

Male
Female

Spayed/Neutered? *

Due to state law and insurance requirements, as well as helping us control and prevent the spread of infectious diseases within our hospital, ALL hospitalized and boarded pets must be current, or updated at the time of admission, for all vaccinations recommended in our preventive health care program against infectious diseases.

DISCLAIMER, WAIVER, and BLANKET PERMISSION FOR TREATMENT I understand every effort will be made to achieve a successful outcome and to provide for all possible safety for my pet. I hereby authorize this hospital to receive, prescribe for, treat, and/or perform surgery upon the pet(s) listed above as well as any additional pets I present in the future. 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 agree to pay for the reasonable costs of collection in the event that collection efforts become necessary. I understand that a service fee of $35.00 will be assessed for each non-sufficient funds check. 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 you are hereby authorized to dispose of the pet as you deem best and/or necessary.

Signature *

Clear Signature

Date *