New Client Form

Owner's Name*

First Last

Date of Birth*

Primary Phone*

Secondary Phone

Email*

Address*

Street Address Address Line 2 City State ZIP Code

Co-Owner's Name*

First Last

Co-Owner's Phone

Co-Owner's Email

Pet's Name*

Species*

Cat
Dog

Pet Breed*

Pet Color*

Pet Birthday/Age*

Sex*

Male
Male (Neutered)
Female
Female (Spayed)

Add another pet?*

No
Yes

Second Pet's Name*

Second Pet's Species*

Cat
Dog

Second Pet's Breed*

Second Pet's Color*

Second Pet's Age/Date of Birth*

Second Pet's Sex*

Male
Male (Neutered)
Female
Female (Spayed)

We appreciate payment when services are rendered.*

Our practice is committed to providing the best treatment to our patients. Our prices are representative of the usual and customary charges for our area. We do not permit billing agreements. We will gladly prepare a written estimate if you desire, please just ask us! We accept all major credit cards, cash, and check. There will be a service charge for any check returned unpaid. Please be aware that if a balance remains unpaid, we may refer your account to a collection agency and you and your family members may be discharged from this practice. To prevent the spread of infectious diseases, all hospitalized patients must be current on all vaccines and free from internal and external parasites. The signature below authorizes this level of preventative care and the appropriate charges will be assessed in the discharge invoice. Thank you for understanding our payment policy. By signing below, I certify that I am 18 years of age or older and that I have read, fully understand and agree to the terms of this agreement, and I sign it voluntarily with full knowledge of its significance.

I have read and understand.

Owners Digital Signature*

Date

Phone

This field is for validation purposes and should be left unchanged.

Please complete this form before your visit.

Welcome to Austin Bluffs Animal Clinic

Address

Contact Info

Hours