Country Club Veterinary Clinic New Client Registration & Pet Information

Country Club Veterinary Clinic New Client Registration & Pet Information

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
Email Address *
example@example.com
Owners Date of Birth *
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 Ferret Reptile Rodent
Breed
Color
Species (if exotic)
Age
Microchip Number
Vaccination History (provide 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 Ferret Reptile Rodent
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 Ferret Reptile Rodent
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 the undersigned, owner or authorized agent of the above admitted patient, 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
Signature *

Clear
Date *

Month Day Year
Date
Should be Empty:

Country Club Veterinary Clinic New Client Registration & Pet Information

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.