Name *

First

Last

Email *

Primary Phone *

Secondary Phone *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

How did you find out about our hospital? *

Internet Search
Drive by
Referral

If you were referred by someone, who should we thank? *

Pet Information

Pet's Name *

Species (dog, cat, etc.) *

Breed *

Color *

Age/Date of Birth *

Sex *

Male
Male Neutered
Female
Female Spayed

Which hospital will you be visiting? *

Please explain the reason for visit. *

Your driver's license will be requested during the check-in process. *

I have read and understand.

If you have any questions, please do not hesitate to ask. We are here to provide the best veterinary care available for your pet. By signing this form, you agree to the foregoing terms of payment. *

I have read and understand.

By submitting this form, I hereby authorize the veterinarian to examine, prescribe for, or treat the above described pet. I assume responsibility for all charges incurred in the care of this animal. I also understand that these charges will be paid at the time of release and that a deposit may be required for surgical treatment. *

I have read and understand.

Pets are sometimes presented to our hospital that are impossible to handle without exposing our staff and patients to unacceptable risk of injury. With an aggressive animal a satisfactory examination and proper treatment cannot be performed without reducing the quality of care that we can provide. For the safety of our patients, clients, and staff Animal Clinic Inc. Will NOT provide services to animals that display unmanageable or aggressive behavior. The pet owner is responsible for any and all charges up to the time treatment is terminated. *

I have read and understand the Animal Clinic Inc. policy regarding aggressive animals.

Signature *

Clear Signature

Date *

New Client Form

Pet Information

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