New Patient Form

Today's Date

Pet's Name

Species/Breed

Pet's Age (Year/Month/Weeks)

Sex

• Male
• Female

Female

• Spayed
• Unknown
• Choice 3

Male

• Neutered
• Unknown

Client Name

Spouse/Alternate Caretaker

Address

Apt

City/State

Zip Code:

(Please indicate who can be reached at each phone number)

Best contact phone number

Name

2 nd contact phone number

Name

3 rd contact phone number

Name

Email *

How did you find us?

We would like to thank them and let them know how your pet is doing. If you found us online, please note the specific website.

PAYMENT POLICIES Professional fees are due at the time services are rendered. We ACCEPT - Visa, MasterCard, Discover, American Express, Cash & Debit Cards. No checks are accepted. A deposit is required when an animal is admitted for medical and surgical services. This is 100% of the initial estimate. Any additional payment is due when your pet is discharged from the hospital. I understand that I will be responsible for any collection fees incurred if my account balance is forwarded to collections.

Signature (My signature indicates that I understand that I am responsible for all fees incurred in treating my pet)

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