850-536-6519
[email protected]
Facebook
Instagram
Facebook
Instagram
Home
About Us
Our Team
Under Construction
Photo Gallery
What to Expect
Payment Options
Services
Online forms
New Client Form
Medicine Refill Request
Contact
Appointment
Select Page
New Client Form
APPOINTMENT
Please complete this form before your visit.
Please enable JavaScript in your browser to complete this form.
Name
*
First
Last
Driver’s License #
*
Email
*
Address
*
Address Line 1
Address Line 2
City
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
State
Zip Code
Cell Phone
*
Employer
Work Phone
Preferred Method of Contact
*
Email
Phone
Postal Mail
Spouse/Co-Owner Name
First
Last
Spouse/Co-Owner Phone
How did you learn about our practice?
*
Notify in case of emergency
*
Cell Phone
Work Phone
Pet Information
Pet's Name
*
Species
*
Dog
Cat
Other
If other, please specify.
*
Breed
*
Age/Date of Birth
*
Color
*
Sex
*
Male
Neutered Male
Female
Spayed Female
Diet or brand fed
*
How often fed?
*
Current medication
Any known allergies or drug sensitivities
Reason for pet’s visit
*
Previous veterinarian where we may ask for previous medical records
*
Will you allow images of your pet on our website or social media?
*
Yes
No
PAYMENT – Read the following carefully and sign below.
PAYMENT IS REQUIRED WHEN SERVICE IS RENDERED. DEPOSIT IS REQUIRED ON ALL HOSPITALIZED ANIMALS. We will gladly prepare a written estimate of service fees if you desire (please ask our doctor or receptionist). We accept cash, major credit cards, and Care Credit. Note: we do not accept checks
*
I have read and agree.
I certify that I have ordered, or have been authorized by the owner to order the named services for the above described animal. In any event, I accept full financial responsibility for the payment for services ordered and rendered.
*
I have read and agree.
To prevent the spread of infectious diseases, all hospitalized patients must be current on all vaccines (dogs – Rabies, DHPP and Bordetella vaccines; cats – Rabies and FVRCP vaccines) and free from internal and external parasites. The signature below authorizes this level of preventative care and the appropriate charges will be assessed in the discharge invoice.
*
I have read and agree.
Signature
*
Clear Signature
Date
*
Email
Submit