Country Club Veterinary Clinic New Client Form

Country Club Veterinary Clinic New Client Form

Fill out the form with your pet’s information
Owner's Name *
Phone *

Area Code Phone Number
Cell *
Spouse's Name & Phone / Cell

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Email Address *
example@example.com
Driver's License # State Exp,
How did you hear about our clinic?
Pet #1
Name
Gender

Male Female
Spayed / Neutered

Yes No
Kind of Pet

Dog Cat Rabbit Bird Ferret Reptile Rodent Fish
Breed
Color
Species (if exotic)
Age
Microchip Number
Vaccination History (provides dates if known)
Distemper
Rabies
Bordetella
Leukemia
Heartworm Test
Pet #2
Name
Gender

Male Female
Spayed / Neutered

Yes No
Kind of Pet

Dog Cat Rabbit Bird Ferret Reptile Rodent Fish
Breed
Color
Species (if exotic)
Age
Microchip Number
Vaccination History (provides dates if known)
Distemper
Rabies
Bordetella
Leukemia
Heartworm Test
Pet #3
Name
Gender

Male Female
Spayed / Neutered

Yes No
Kind of Pet

Dog Cat Rabbit Bird Ferret Reptile Rodent Fish
Breed
Color
Species (if exotic)
Age
Microchip Number
Distemper
Rabies
Bordetella
Leukemia
Heartworm Test
** Payment is Expected at the Time Services are Rendered ** We accept cash, in-state checks, Visa, MasterCard, and Care Credit.
By checking this field I here by authorize the doctors of Country Club Veterinary Clinic to administer such treatment as is necessary and to perform procedures therapeutically and/or diagnostically. I further understand that no guarantee of successful treatment is made. I also assume financial responsibility for all charges incurred, and agree to pay all such charges at the time of release. I understand that unpaid balances over 30 days are subject to a monthly 1.5% (18% APY) finance charge. Any balance that I leave unpaid will be forwarded to our collection agency, and will incur a 25% collection fee for which I am liable, in addition to monthly finance charges. There will be a $35 fee charged for any check that is returned. At your request we will gladly discuss cost of services and/or prepare a written estimate of recommended procedures/treatments. Deposits may be required for pets being admitted into the hospital. *

Yes
Should be Empty:

Country Club Veterinary Clinic New Client Form

Pet #1

Pet #2

Pet #3

** Payment is Expected at the Time Services are Rendered ** We accept cash, in-state checks, Visa, MasterCard, and Care Credit.

Payment is Expected at the Time Services are Rendered We accept cash, in-state checks, Visa, MasterCard, and Care Credit.