New Client Info

Client Information

How did you hear about us?

Please enter the name of you friend.

Please tell us how you heard about us.

First Name *

Last Name *

Spouse Name

Address *

City *

State *

Zip Code *

Email *

Phone *

Spouse Phone

Alternate Emergency Contact Name

Alternate Emergency Contact Phone

Pet Information

Number of Pets *

Pet 1

Name *

Dog/Cat *

Dog

Cat

Breed *

Color/Markings *

Age or DOB *

Male/Female *

Male

Female

Spayed/Neutered? *

Yes

Microchip #

Pet 2

Name *

Dog/Cat *

Dog

Cat

Breed *

Color/Markings *

Age or DOB *

Male/Female *

Male

Female

Spayed/Neutered? *

Yes

Microchip #

Pet 3

Name *

Dog/Cat *

Dog

Cat

Breed *

Color/Markings *

Age or DOB *

Male/Female *

Male

Female

Spayed/Neutered? *

Yes

Microchip #

Pet 4

Name *

Dog/Cat *

Dog

Cat

Breed *

Color/Markings *

Age or DOB *

Male/Female *

Male

Female

Spayed/Neutered? *

Yes

Microchip #

Current Veterinarian

Do you currently have a family veterinarian? *

Yes

Would you like us to contact a previous vet for records for your pet?

Yes

Previous Clinic Name

Current Clinic Name - We will update your family veterinarian regarding your visit today.

Acknowledgment and Signature

I understand that payment is expected at the time services are rendered. I hereby authorize the staff of Creekside Pet Care Center to render any treatment which is deemed necessary to the health of my pet(s) while in custody of the hospital. I understand that in the event of any unusual or emergency circumstances, the staff will make every attempt to contact me or my designated representatives before, if time permits, proceeding with the treatment. I understand that I will be financially responsible for all emergency procedures including the Estimate of Charges provided to me in person or over the telephone. I understand that a deposit is required for all pets admitted to the hospital. I understand that if my account is not kept in good standing, a fi nance fee of $25 will be added to the account and it will be forwarded to a third-party collections agency, which may affect my credit rating. *

I have read and agree to the statement above.

Signature of Owner / Agent / Good Samaritan *

Clear

Date *

Captcha

If you are human, leave this field blank.

Client Information

Pet Information

Pet 1

Pet 2

Pet 3

Pet 4

Current Veterinarian

Acknowledgment and Signature

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