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541-382-0741
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Services
Dogs
Cats
Exotic Pets
Dental Services
Wellness Plans
Stem Cell Therapy for Pets
Surgeries, Laser Treatments and Post Care
Wellness Plans
About
Doctors & Staff
Philanthropy & Partnerships
Contact
Forms
Pre Visit Questionaire
New Client Information Form
Boarding Authorization Form
Pet Sitter Authorization Form
541-382-0741
New Client Form
Thank you for giving us the opportunity to care for your pet(s). To insure the best care possible, please take the time to fill out this form in its entirety.
About You
Owner's Name
*
First
Last
Address
*
Street Address
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
Phone
*
Email
We agree to keep all personal information confidential. We will never share or sell your information.
Cell Phone (If different from home phone)
Co-Owner/Emergency Contact
*
First
Last
Emergency Contact Phone
*
Owner's Employer
*
Owner's Work Phone
Co-Owner's Employer
*
Co-Owner's Work Phone
How Did You Learn About Our Clinic
Website
Drive By
Recommendation
Phone Book
News Publication
Other
If Recommended, by whom?
About Your Special Companion
Pet's Name
*
Type of Animal
*
Dog
Cat
Reptile/Amphibian
Bird
Other
Breed
Color
Birthday
MM slash DD slash YYYY
Sex
*
Male
Female
Neutered
Spayed
Check this box if you DO NOT want your pet's picture or name to appear on our website, Facebook, or any promotional materials.
Name of Previous Vet Clinic
Phone
Do we have permission to contact them for health records?
Yes
No
Medical and Vaccine History
Please give a complete description and dates
We accept cash, check, debit, Visa, MasterCard, American Express, Discover, and Care Credit. In case of extensive medical services a deposit may be required. We will gladly prepare an estimate for services upon request. There will be a $25 charge for all returned checks. By sending this form, I hereby authorize the veterinarian to examine, prescribe medication for, or treat my pet and I assume full responsibility for all charges incurred in doing so.
Services
Dogs
Cats
Exotic Pets
Dental Services
Wellness Plans
Stem Cell Therapy for Pets
Surgeries, Laser Treatments and Post Care
Wellness Plans
About
Doctors & Staff
Philanthropy & Partnerships
Contact
Forms
Pre Visit Questionaire
New Client Information Form
Boarding Authorization Form
Pet Sitter Authorization Form
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