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.
CellHomeWork
Primary Email
example@example.com
Secondary Contact Name

First NameLast Name
Secondary Phone Number
Please enter a valid phone number.
CellHomeWork
Secondary Email
example@example.com
How did you hear about us?

LocationGoogleFacebookReview SiteReferralOther
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*

YesNo
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?*

YesNo
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: *

Clear
Date

MonthDayYear
Date
Please select patient species*

CanineFeline
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?*

MaleFemale
Is your dog Neutered/Spayed?*

YesNoUnsure
Please select which applies*

I brought my pet’s medical records todayMy pet does not have any previous medical records.Please call to get my pets medical records
Please provide the phone number to your previous vet to help us obtain your pet's medical records
Please enter a valid phone number.
Is your dog allowed to have peanut butter and treats while in the clinic?*

YesNo
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?*

MaleFemale
Is your cat Neutered/Spayed?*

YesNoUnsure
Please select which applies*

I brought my pet’s medical records todayMy pet does not have any previous medical records.Please call to get my pets medical records
Please provide the phone number to your previous vet to help us obtain your pet's medical records
Please enter a valid phone number.
Is your cat allowed to have treats while in the clinic?*

YesNo
Please list all other pets in the household:
Should be Empty: