Please check in 15 minutes prior to your appointmentThank you for giving us the opportunity to care for your pet(s). To help us better understand you and your pets’ needs, please complete this form and return it to a reception team member.CLIENT INFORMATIONName* First Last Drivers License (State & Number): Email Address:* Primary Phone:* Secondary Phone: Work Phone: How would you like to be contacted for reminders?* Phone Email Mail Text None Mailing Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Physical Address (if different): Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Employer: Spouse/Co-Owner: Primary Phone: Secondary Phone: Emergency Contact Name:* Primary Phone:* Secondary Phone: How did you hear of our practice? Patient Information*Pet NameSpeciesAge/DOBBreedColorSex (m/f/s/n) Name of previous Veterinary office? May we contact them to get your pets’ previous history? DUE TO STATE LAW REQUIREMENTS, ALL DOGS AND CATS MUST BE CURRENT ON RABIES VACCINATION.Do you have verification of your pet's previous Rabies vaccination? Yes No Prior Surgery: Prior Illness: Need to schedule an appointment?* Yes No If yes, please enter date and time you would like to request. (subject to availability). Please do not choose a Saturday or Sunday, as that will not be able to be accommodated.Appointment Date* MM slash DD slash YYYY Appointment Time : Hours Minutes AM PM AM/PM FULL PAYMENT IS DUE AT THE TIME OF SERVICE. WE ACCEPT CASH, CHECK, VISA, MASTERCARD, DISCOVER, SCRATCHPAY AND CARE CREDIT New clients are required to make a deposit (equal to one exam fee per animal) to secure their appointment. This will be applied to your account; please note that this deposit is forfeit if you cancel with less than 24 hours’ notice or fail to show up for your appointment. By signing below, you acknowledge that you are the owner of the pet(s) listed within this form and that all fees assessed during your pet(s) visit will be paid for at the time of service. Any balance older than 30 days may be charged a monthly billing fee of $4.00 and monthly interest of 0.875% (no less than $5.00)Date* MM slash DD slash YYYY Signature*
