Name *

First

Last

Email *

Primary Phone *

Secondary Phone

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Drivers License

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

First

Last

Phone

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 *

Birthdate/Age *

Color *

Weight *

Sex *

Male
Neutered Male
Female
Spayed Female

Spayed/Neutered? *

Yes
No

Does your pet have a microchip identification? *

Yes
No

What is the microchip number?

Is your pet on any medications? *

Yes
No

Please Specify: *

Is your pet allergic to any medication?

Yes
No

Please Specify: *

Pet's Diet:

Payment is due in full at the time that services are performed. If being admitted into the hospital, we cannot begin the care of 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 the only way that we have of knowing for certain that you want us to proceed with the care of your Pet. We accept Cash, Visa, MasterCard, Discover, and CareCredit or Scratch Pay payments. 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.

New Client Form

New Client Form

Using CareCredit for Veterinary Financing

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