Eagle Creek Animal Clinic - New Client Form

Eagle Creek Animal Clinic - New Client

At Eagle Creek Animal Clinic, we love meeting new clients and their pets!
Client Information
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Spouse/Co-Owner Name

First NameLast Name
Contact Information
Primary Contact Name

First NameLast Name
Primary Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Primary Email
example@example.com
Secondary Contact Name

First NameLast Name
Secondary Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Secondary Email
example@example.com
How did you hear about us?

Other
If you heard about us from a referral, please provide their name here:
Consent
Photo Consent: Do we have permission to take pictures of your pet and post them to our website and/or Facebook page
Medical Records Release Consent: Do you consent to having your medical records released to other pet professionals such as groomers, boarders, trainers and veterinarian offices?
Treatment Consent: I hereby authorize the veterinarian to examine, prescribe for or treat my pets to the best of their abilities. I assume responsibility for all charges incurred in the care of my pets. (Please initial)
Financial Policies

Full payment is due at the time of service. We accept Visa, Mastercard, Discover, American Express, Care Credit, Cash, and Check. The returned check fee is $25.

If you have payment concerns, please discuss with a staff member BEFORE your pet is examined. We can provide you with a written treatment plan including pricing prior to services being rendered.

Missed Appointment Policy: If you miss an appointment without notifying the clinic at least 4 hours before the scheduled time you may be charged a $35 missed appointment fee.
Your signature here indicates your agreement with the above policies and consent:
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Please select patient species
Canine Pet - Patient Information
Dog's Name
Breed
Color/Markings
Date-of-Birth or Approximate Age
Previous Veterinary Clinic
Microchip Number
How long have you had your dog?
Current Dog Food
What gender is your dog?
Is your dog Neutered/Spayed?
Please select which applies
Please provide the phone number to your previous vet to help us obtain your pet's medical records
Please enter a valid phone number.Format: (000) 000-0000.
Is your dog allowed to have peanut butter and treats while in the clinic?
Feline Pet - Patient Information
Cat's Name
Breed
Color/Markings
Date-of-Birth or Approximate Age
Previous Veterinary Clinic
Microchip Number
How long have you had your cat?
Current Cat Food
What gender is your cat?
Is your cat Neutered/Spayed?
Please select which applies
Please provide the phone number to your previous vet to help us obtain your pet's medical records
Please enter a valid phone number.Format: (000) 000-0000.
Is your cat allowed to have treats while in the clinic?
Please list all other pets in the household:
Should be Empty: