New Client Form

Primary Contact Information

Primary Contact*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Email*

Home Phone*

Cell Phone

Place of Employment

Secondary Contact Information

Secondary Contact on Account

First Last

Secondary Contact Number

Pet Information

Pet Name*

Breed

Age/Date of Birth

Coloring

Species

Cat
Dog

If other, please specify.

Sex*

Male
Male Neutered
Female
Female Spayed

Do you have pet insurance?*

Yes
No

Health History

Date of Last Vaccines

Where did your pet last receive vaccinations?

ALL PROFESSIONAL FEES ARE DUE AT THE TIME OS SERVICES RENDERED. We accept cash, local checks, Master Card, Visa, Discover, American Express, and CareCredit. There will be a service charge, as allowed by law, for any check returned unpaid and on any unpaid balances that are 30 days overdue. We also reserve the right to charge a Statement Handling Fee on any accounts that are not paid in full at the time of services rendered. To prevent the spread of infectious diseases, all hospitalized and boarded patients must be current on all vaccines and free from internal and external parasites. Your signature below authorizes this level of preventive care and the appropriate charges will be assessed in the discharge invoice. *

Consent*

I have read this form and agree to the terms.

Digital Signature*

Today's Date*

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Primary Contact Information

Secondary Contact Information

Pet Information

Health History

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Veterinary Hospital

Adventure Camp & Pet Lodge