Client Information

Client Information Form

Thank you for giving us the opportunity to care for your pets. So that we become better acquainted, please complete the following.

Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Home Phone Number *

Cell Phone Number *

Work Phone Number *

Email *

Driver's License Number: *

Employer: *

Spouse/Partner Name *

First

Last

Spouse/Partner Phone Number *

Spouse/Partner Employer *

Would you like to be present during your pet's treatment? *

Yes No

How did you become aware of our clinic? *

If a referral sent you, who may we thank? *

Why did you decide to visit us? *

Who is your current Veterinarian? *

Professional services are to be paid at the time services are rendered. Please select the preferred method of payment below.

Preferred method of payment? *

BY SUBMITTING THIS FORM, YOU ARE RESPONSIBLE AND AGREE TO PAY IN FULL THE TOTAL CHARGES FOR SERVICES RENDERED AT THE TIME OF DISCHARGE AND ANY FEES INCURRED FOR COLLECTION OF SAID CHARGES. I UNDERSTAND THAT THE FEES ARE BASED ON TREATMENT DEEMED NECESSARY AT THE TIME OF EXAM, TREATMENT OR ADMISSION AND THAT THE ESTIMATED FEE MAY BE RAISED OR LOWERED BY THE ADMINISTRATION OF TREATMENT, MEDICATION, OR DIAGNOSTIC TEST.

Client Information Form

Thank You!