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Home
Services
Clients
- New Client Form
Pharmacy

New Client Form

Owner's Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State ZIP Code

Home Phone

Cell Phone

Which number is best to reach you?(Required)

Home

Cell

Can you receive text messages?

Yes

No

Email(Required)

Add a Co-Owner?(Required)

Yes

No

Name

First Last

Home Phone

Cell Phone

Previous Vet:

Previous Vet's Phone Number

Whom should we thank for referring you?

PET HEALTH HISTORY

Pet's Name(Required)

Sex

Male

Female

Neutered/Spayed?

Yes

No

Breed(Required)

Color(Required)

Birthdate or Age(Required)

Current Medications

Please bring and give any medical records/vaccine records to the receptionists to make copies.

OFFICE POLICIES

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.(Required)

I have read and agree.

I understand that if I no-show for an appointment, a $50 deposit will be required to schedule future appointments.(Required)

I have read and agree.

I understand that payment is ALWAYS DUE IN FULL at time of service. A deposit of 50% of the treatment plan may be required before treatments or hospitalization of your pet. I recognize that financial concerns should be discussed PRIOR to examination and treatment.(Required)

I have read and agree.

Do we have your permission to share your pet’s image and story on our social media, website, and other forms of related media?(Required)

Yes

No

I authorize my emergency contact (other than myself) to pursue treatment if I am unavailable. Your emergency contact must be an adult over the age of 18.(Required)

I have read and agree

Emergency Contact(Required)

First Last

Phone(Required)

Signature(Required)

Date(Required)

MM slash DD slash YYYY

File

Max. file size: 128 MB.

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Hospital Hours

Monday: 8:00am-7:00pm
Tuesday: 8:00am-6:00pm
Wednesday: 8:00am-6:00pm
Thursday: 8:00am-7:00pm
Friday: 8:00am-6:00pm
Saturday: 9:00am-1:00pm
Closed Sunday

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