"*" indicates required fields We are pleased to welcome you to our practice. Please take a few minutes to fill out this form. If you have questions we’ll be glad to help you. We look forward to working with you maintaining your pet’s health. Client InformationDate* MM slash DD slash YYYY Name* First Middle Last Driver's LicenseSSN#Date of Birth MM slash DD slash YYYY 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 Contact NamePrimary PhoneContact NameSecondary PhoneEmail Permission to use photos of your pets on Social Media Yes No EmployerEmployer #Spouse EmployerEmployer #Emergency ContactPhone #Pet InformationPet's NameSpecies Cat Dog Other Sex Male Female Neutered / Spayed? Yes No At what age?BreedColorDOB / AgeLate Fee/No-Show Policy Any client arriving more than 20 minutes late for their scheduled appointment time will be assessed a $25 late fee. Any client who fails to arrive for a scheduled appointment without cancelling/rescheduling 24 in advance is considered a “no- show”. After 1 “no-show” appointment, a $25 non-refundable deposit will be required to schedule all new appointments. After 3 “no-show” appointments, the non-refundable deposit will increase to $50. I certify I have read and understand the Late Fee/No-Show Policy(Initial)PaymentWe will gladly prepare an estimate of service fees if you desire. (Please ask your technician or Dr.). All professional fees are due at the time of the services are rendered. There will be a service charge for any check returned unpaid. The signature below authorizes this level of preventative care and the appropriate charges will be assessed in the discharge invoice. Signature*Date* MM slash DD slash YYYY EmailThis field is for validation purposes and should be left unchanged.
