New Client Form New Client Form Client Information Thank you for giving us the opportunity to care for your pet(s). Please help us to better meet your needs by taking a moment to complete both pages of this information sheet. Primary Owner Information Are You a New Client? * Yes No If you are an existing client please use our Appointment Form. Name * Name First First Last Last Date * Email * Address * Address Address Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Home Phone Cell Phone Work Phone How may we contact you for appointment reminders, general inquiries, visit summaries, etc.? * Text Email Phone Call OtherOther Secondary / Alternate Owner Information Name Name First First Last Last Email Home Phone Cell Phone Work Phone How did you hear about us? * The Internet Hospital Sign Individual, someone we may thank?Individual, someone we may thank? OtherOther TO PREVENT THE SPREAD OF INFECTIOUS DISEASES AND PARASITES, ANIMALS HERE FOR BOARDING, BATHS, AND NON-SICK VISIT DROP-OFF APPOINTMENTS MUST BE CURRENT ON ALL REQUIRED VACCINATIONS AND FREE OF INTERNAL / EXTERNAL PARASITES. HOSPITALIZED AND / OR SICK VISIT DROP-OFF APPOINTMENTS WILL BE EVALUATED BY A DOCTOR PRIOR TO ANY VACCINATION(S) BEING ADMINISTERED. PAYMENT IS DUE AT THE TIME SERVICES ARE RENDERED. We accept all major credit / debit cards, cash, and Care Credit. In order to abide by Care Credit guidelines, this method may only be used if the individual whose name is on the card is present at the time of the transaction. We will gladly prepare an estimate if you would like, just ask a staff member or doctor. I authorize Midtown Veterinary Practice consent to treat my pet(s). * Yes No Carefully read and select AT LEAST one of the following: * I authorize Midtown Veterinary Practice to provide emergency medical treatment at the discretion of the veterinarian and will accept any cost incurred. I authorize Midtown Veterinary Practice to provide emergency medical treatment at the discretion of the veterinarian after a verbal estimate is presented. I DO NOT authorize Midtown Veterinary Practice to provide emergency medical treatment with the understanding that Midtown Veterinary Practice is not liable if my pet becomes ill. Signature * signature keyboard Clear Who's signature? * Owner Agent Today's Date * Captcha If you are human, leave this field blank. Next
