Name *

First

Last

Email *

Primary Phone Number *

Secondary Phone Number

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Who else is authorized to make decisions about your pet's healthcare? *

First

Last

Phone Number

How did you find out about our hospital? If you were referred by someone, who should we thank? *

Pet's Name *

Species (Dog, Cat, Etc.) *

Breed *

Age/Date of Birth *

Sex *

Male
Neutered Male
Female
Spayed Female

Does your pet have a microchip for identification? *

Yes
No

What is the microchip number?

Do you have a second pet? *

Yes
No

Pet's Name *

Species (Dog, Cat, Etc.) *

Breed *

Age/Date of Birth *

Sex *

Male
Neutered Male
Female
Spayed Female

Does your pet have a microchip for identification? *

Yes
No

What is the microchip number?

Do you have a third pet? *

Yes
No

Pet's Name *

Species (Dog, Cat, Etc.) *

Breed *

Age/Date of Birth *

Sex *

Male
Neutered Male
Female
Spayed Female

Does your pet have a microchip for identification? *

Yes
No

What is the microchip number?

Do you have a fourth pet? *

Yes
No

Pet's Name *

Species (Dog, Cat, Etc.) *

Breed *

Age/Date of Birth *

Sex *

Male
Neutered Male
Female
Spayed Female

Does your pet have a microchip for identification? *

Yes
No

What is the microchip number?

Do you have a fifth pet? *

Yes
No

Pet's Name *

Species (Dog, Cat, Etc.) *

Breed *

Age/Date of Birth *

Sex *

Male
Neutered Male
Female
Spayed Female

Does your pet have a microchip for identification? *

Yes
No

What is the microchip number?

Payment is due in full at the time that services are performed. If your pet is admitted into the hospital, we cannot start caring for your pet until you have confirmed your desire to do so by 1) signing the Client Consent & Estimate Form and 2) leaving an initial deposit of 50% of the upper end of the estimate. This is our only way of knowing for certain that you want us to proceed with the care of your pet. We accept cash, credit cards, checks, CareCredit, and Scratchpay as payment. We neither extend credit nor bill for services. All open invoices are sent to collections after 45 days unless prior arrangements are made. *

I have read and accept the financial policy.

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New Client Form

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