New Client FormYour Name* First Last Spouse NameAddress* 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 Primary Phone*Alternate PhoneDOB* MM slash DD slash YYYY Employer*Spouse’s EmployerDriver License Number*Email* (We will not share your email and will use it to send you information regarding your pets and/or account only)How did you become aware of our clinic?*May we take a photo of your pet(s) for our records?* Yes NoMay we share your pet’s photo(s) on our website and/or social media pages?* Yes NoPatient InformationName*Breed*Birthdate* MM slash DD slash YYYY Color(s)*Sex* Male FemaleSpayed or Neutered?* Yes NoKnown Medication Allergies?*Previous Vet*Add another pet?* Yes NoName*Breed*Birthdate* MM slash DD slash YYYY Color(s)*Sex* Male FemaleSpayed or Neutered?* Yes NoKnown Medication Allergies?*Previous Vet*Add third pet?* Yes NoName*Breed*Birthdate* MM slash DD slash YYYY Color(s)*Sex* Male FemaleSpayed or Neutered?* Yes NoKnown Medication Allergies?*Previous Vet*Add fourth pet?* Yes NoName*Breed*Birthdate* MM slash DD slash YYYY Color(s)*Sex* Male FemaleSpayed or Neutered?* Yes NoKnown Medication Allergies?*Previous Vet*Payment in full is required at the time services are rendered. Please circle your form(s) of payment:* Cash Visa MasterCard Debit/ATM CareCreditWe are unable to accept checks.Release and Authorization* I hereby authorize the veterinarian to examine, prescribe for, or treat my pet(s). I assume financial responsibility for all charges incurred. I understand that I will be given an explanation of necessary procedures and an estimate of costs prior to incurring any expense greater than $150.00 total, unless I request otherwise. I also understand that all charges must be paid in full at the time of discharge.Signature*CAPTCHAΔ