Welcome Form Welcome Form Client InformationName* First Name Last Name Co-owner Name Spouse/Co-Owner First Name Last Name Mailing Address* Street Address City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Email* Phone NumbersCellOkay to receive text messages? Yes HomeWorkAlternate ContactPhoneFinancially Responsible PartyPhonePet Information>>> Click on the '+' at the right to add more pets. >>>Pet's NameDog/Cat/?BreedColorGenderAge/DOB Enter each pet on a separate line. Click on the '+' symbol on the right to add more lines.How would you like to receive your pet's reminders?TextEmailPostcardHow would you like to receive your pet's appointment reminders?PhoneTextEmailDo you authorize your pet's picture to be featured on social media?YesNoNo Show Policy to Appointments: As a courtesy to our clinic and to avoid a $47 no show fee, please call us 24 hours in advance if you need to change or cancel your appointment.Unpaid Invoices:Any unpaid invoice will be sent to collections and billed twice the amount to include collection fees. The monthly interest rate on outstanding account balances is 5%, with a $5.00 fee.Authorization*I hereby authorize the veterinarian to examine, prescribe for , or treat the above referenced pet(s). I assume responsibility for all charges incurred in the care for the animal(s). I also understand that ALL PROFESSIONAL FEES ARE DUE AT THE TIME SERVICES ARE RENDERED. Yes, I agree.
