New Client Form

Please fill out the following form before your scheduled appointment.

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New Client Form

Please fill out the following form as thoroughly as possible before your scheduled appointment. Please note: All * fields are required. If you have any questions, please don’t hesitate to call us.

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Client Name *

First

Last

Additional Authorized User Name:

Additional Authorized User Phone:

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone *

Work Phone

Cell Phone

E-Mail Address *

Would you like reminders sent to you via e-mail? *

Pet Name *

Breed *

Age/DOB *

Gender: *

Color: *

Spayed or Neutered? *

Known Allergies:

Medical Concerns:

How did you hear about us?

(client referrals receive $15 credit to account)

Is your pet on heartworm preventative?

Is your pet on flea & tick preventative?

What is the reason for your visit today?

I hereby authorize the veterinarian to examine, treat and prescribe for the above described pet. I assume responsibility for all charges incurred in the care of the pet. I also understand that all professional fees are due at the time service is rendered. In the event that an invoice is not paid in full and is sent to collections, a 40% price adjustment will be added to the total due to collection fees. On occasion, my or my pet’s likeness may be captured on video or other media. I hereby authorize Foothills Animal Clinic and Heartland Veterinary Partners to use, broadcast, and/or reproduce my and my pet’s likeness in video, print, or other media. I understand I will not be compensated for any such use. *

I authorize

Signature of client responsible for pet(s) *

Clear Signature

Date *

New Client Form

Forms

New Client Form

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Questions?

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Contact

Address

Hours