New Client Form

First Name*:

Last Name*:

Address*:

Address, Line 2:

City*:

State*:

Zip/postal*:

Email*:

Phone*:

Home Phone:

How did you hear about us?

Patient Information:

Pet's Name

Age / DOB

Species

Breed

Sex

Is your pet neutered or spayed?

Yes

Are your pet's vaccines current?

Yes

Name of former veterinary practice

Do you have pet's medical records?

Yes

If yes, please upload medical records.

(pdf, doc, jpg, png files only) (1 MB max)

If you cannot upload previous records, may we request a transfer?

Yes

Would you like us to call you for your appointment?

Yes

Reasons or conditions that prompted your visit?

Special requests or conditions?

Please list any additional pets here

I understand, by indicating I agree and submitting this registration, that I am responsible for any charges incurred by my pet while in the care of the doctors at Cottner Creek Pet Clinic and that charges are due and payable at the time of service, unless other arrangements are made in advance. Any balance that is carried over a period of 30 days will accrue a monthly finance charge of 1.5% or 18% per annum. Any balance that I leave unpaid will be forwarded to Cottner Creek Pet Clinic's collection agency and will incur a 25% collection fee for which I am liable, in addition to monthly finance charges.

I have read this statement and -*

I Agree

I Disagree

Client Information

Patient Information:

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