757-599-3326
frontdesk@pinemeadowvet.com
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New Client Form
Please fill out this form as completely and accurately as possible so we can get to know you and your pet(s) before your visit.
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New Client Form
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Owner(s) Name
*
First
Last
Any Additional Authorized Guardians
Address
*
Address Line 1
Address Line 2
City
--- Select state ---
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Zip Code
Phone Number
*
Home/Cell/Work
Who does it belong to?
Can it receive texts?
Email Address
*
Preferred method of contact
*
Phone
Email
Text Message
If you are new to our hospital, how did you become aware of us?
*
Website
Sign
Facebook
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Friend or Family Referral
Whom may we thank for your visit?
*
Do you have pet insurance?
*
Yes
No
What type?
May we use photos of your pet(s) on our website, Facebook and Instagram accounts?
*
Yes
No
May we release your phone number, name and/or vaccine information to the Humane Society, County officials, or individuals that have identified your pet by a rabies vaccine tag or microchip and wish to contact you to return your pet?
*
Yes
No
We accept: Cash & Check / Debit Card / MasterCard / VISA / Discover / American Express / CareCredit
Patient Information
Please fill out the following for your pet(s) under our care:
Patient Name
*
Species (Choose one)
*
Dog
Cat
Other
Other
*
Breed
*
Gender (Choose one)
*
Male
Female
Neutered Male
Spayed Female
Color/Markings
*
Known Allergies
*
Important Medical Issues:
*
Patient Name
Species (Choose one)
Dog
Cat
Other
Other
*
Breed
Gender (Choose one)
Male
Female
Neutered Male
Spayed Female
Color/Markings
Known Allergies
Important Medical Issues:
Terms of Service
I assume full responsibility for all charges incurred and understand that a deposit may be required for hospitalization and/or treatment. I understand that Pine Meadow Veterinary Hospital does not extend credit out of the office, that ALL PROFESSIONAL FEES ARE DUE AT THE TIME OF SERVICES RENDERED, and I agree to pay for these services. I understand that there is a minimum $20.00 service charge on all returned checks. Any unpaid accounts will be subject to a monthly interest charge of 2% and, should my account be assigned for collection, I will be responsible for all court costs and attorney’s fee of thirty-three and one-third percent of all monies due. I hereby authorize Pine Meadow Veterinary Hospital and its staff to examine, prescribe for, and/or treat my pet(s). All information I have provided here is true to the best of my knowledge. I have read and understand the Terms of Service.
Signature of Owner or Financially Responsible Party
Clear Signature
(Must be 18 years or older)
Today’s Date
*
Message
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