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 License SSN# Date of Birth MM slash DD slash YYYY Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Contact Name Primary PhoneContact Name Secondary PhoneEmail Permission to use photos of your pets on Social Media Yes No Employer Employer #Spouse Employer Employer #Emergency Contact Phone #Pet InformationPet's Name Species Cat Dog Other Sex Male Female Neutered / Spayed? Yes No At what age? Breed Color DOB / Age Late 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 CommentsThis field is for validation purposes and should be left unchanged.
