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New Client Information Form
Welcome to YOUR animal clinic!
Where we love your pets like our own!
Thank you for giving us the opportunity to care for your pet(s). So that we may become better acquainted, please complete the following:
Owner`s First Name*
Owner`s Last Name*
Co-Owner/Spouse Name
Address*
Address (Line 2)
City*
State*
Zipcode*
Home Phone*
Work Phone
Cell Phone
Co-owner Phone
Email*
Driver*
Driver`s License - State Issued*
How did you hear about us?*
Pet 1
Pet`s Name*
Species*
Breed*
Color(s)*
Age/DOB*
Gender*
My pet is spayed/neutered:
Any known allergies?*
Special Diet/Medications
Date of last known vaccinations
Where were they administered?
Would you like for us to call for your records from a previous clinic?*
Which clinic should we call for your pet`s records?
Pet 2
Pet`s Name
Species
Breed
Color(s)
Age/DOB
Gender
My pet is spayed/neutered:
Any known allergies?
Special Diet/Medications
Date of last known vaccinations
Where were they administered?
YOUR DRIVER`S LICENSE IS REQUIRED AT REGISTRATION FOR IDENTIFICATION AND INFORMATION VERIFICATION. ALL FEES ARE DUE AND PAYABLE AT THE TIME SERVICES ARE RENDERED. WE DO NOT OFFER FINANCING OR IN-HOUSE CREDIT!
We accept the following forms of payment: Cash, Check, Visa, Mastercard, Discover, American Express, and CareCredit.
Please note: Current vaccinations by a licensed veterinarian are required for the admission of your pet to our hospital. Owner administered vaccinations are not acceptable. This includes admission for elective surgery, boarding, grooming, and well animal care. Proof of vaccinations is required prior to admission and is the responsibility of the client. I agree to allow the doctors and staff of Hernando Animal Clinic to treat my pet and I accept responsibility for all accumulated fees associated with the care that my pet(s) receive. I understand that I am responsible for payment in full prior to discharge according to Hernando Animal Clinic policy and will be held responsible for service or collection fees if balance is not paid in full.
I have read and accept the above-mentioned terms and conditions:*
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