New Patient & Client Form

  • Client Information

  • Patient Information

  • Date Format: MM slash DD slash YYYY
  • Authorization

    I hereby authorize the veterinarian to examine, prescribe for, or treat my pet. I assume full responsibility for all charges incurred in the care of this animal. I also understand that these charges will be paid at the time services are rendered and that a deposit may be required for surgical treatment or extended boarding. If the outstanding bill is not paid within 30 days of the date issued, then I agree to pay a sum of 1 1/2% per month, 18% annum, with a minimum charge of $3.00 per month, on the outstanding balance and attorney fees in addition to the account owed above. Any returned checks will incur a $35.00 fee, without exception. Retuned checks are automatically re-deposited by ResubmitIt.

  • Typing your name above acts as your digital signature.
  • Date Format: MM slash DD slash YYYY