New Client Intake Form | New Port Richey Veterinarian

Client Information

Your Name*

First

Last

Spouse or Co-Owner Name

Address*

Street Address

Address Line 2

City

State

ZIP Code

Primary Phone*

Alternate Phone

Cell Phone

Spouse Cell Phone

Your Email*

Employed By

Emergency Contact Name*

Emergency Contact Phone*

Pet Information

Pet Name

Breed

Pet Color

Date of Birth or Estimated Age

Sex

Male
Female
Spayed
Neutered

Proof of rabies vaccination is required before treatment of any pet. If the pet is not currently vaccinated All Pets Hospital requires immediate vaccination before continuing treatment.

By signing this form you are authorizing All Pets to request medical records from previous veterinary practices.

Previous Vet

I understand that by signing this form I am agreeing to pay for the services and products that my pet receives.
I understand that I may request a written estimate of fees prior to any care provided.
I understand that payment in full is expected when treatment is performed or animal is released from the hospital. Payment may be cash or Credit Card only. WE DO NOT ACCEPT CHECKS.
WE REQUIRE PHOTO ID WITH ANY CREDIT CARD TRANSACTION. NO EXCEPTIONS.
I understand that in case of an emergency hospitalization, deposit arrangements must be made with the receptionist.
I understand that I am liable for any court costs or other fees incurred during the collection of my bad debts.
I understand that All Pets Hospital follows the Federal Trade Commission (FTC) rules. Therefore we do not store in any way credit card numbers, photo ID’s, or any other form of payment for future use. We also are not able to bill, leave outstanding balances, or mail invoices to clients.

How Did You Hear About Us

How did you hear about us?

We love social media! Do we have your permission to share your pet’s image and story on our social media and/or website? Your name and personal information will never be shared; we only use your pet’s first name.*

Yes
No

I have read and agreed to the terms listed above:*

Yes
No

Signature*

Please input your legal first and last name

Today's Date

Comments

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