New Client Information

New Client Information
Please note that patient records must be submitted 48-hours prior to your appointment.
Appointment Date

MonthDayYear
COVID-19 Message
Please let us know if you or anyone in your household has been sick with respiratory symptoms or fever, is potentially positive for COVID-19, or is under quarantine orders from a doctor, so that we can take appropriate precautions.*

Yes, one or more of the conditions listed above applies to me or my household.No, none of the conditions listed above apply to me or my household.
Printed Name for E-Signature for COVID-19 Status*

First NameLast Name
Client Information
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Primary Phone Number*
Please enter a valid phone number
Primary Phone Type*
Email*
example@example.com
Would you like to list a Co-Owner on your account?

YesNo
Co-Owner's Name

First NameLast Name
Co-Owner's Phone Number
Please enter a valid phone number
Co-Owner's Email Address
example@example.com
Pet Information
How many pets would you like to register?*

Primary Veterinarian
Does your pet currently have a primary veterinarian?

YesNo
Primary Veterinarian Office Name
Location
Phone Number
Please enter a valid phone number.
Do we have your permission to contact that veterinarian office to transfer your pet's records to our office?

YesNo

Agreement

We will gladly prepare a written estimate if you desire. Feel free to ask for this with any of our staff.
I, the undersigned owner or authorized agent of the above admitted patient(s), agree to assume responsibility for all charges incurred, and agree to pay all such charges at the time of service/release.

ALL PROFESSIONAL FEES ARE DUE AT THE TIME SERVICES ARE RENDERED.
Printed Name for E-Signature*

First NameLast Name
Today's Date*

MonthDayYear
Are you a robot?*
Should be Empty:

COVID-19 Message