New Client Form | Best Friends Pet Clinic

Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Daytime Phone*

Phone Type*

Nighttime Phone*

Phone Type*

Email

Pet's Name*

Age

Years, Months

Type of Pet*

Breed

Sex*

Male
Female

Neutered/Spayed

Neutered
Spayed

Check if applicable:

Are your pets vaccines current?
Do your have pet's medical records?

Medical records at another veterinary Practice?

Yes
No

Name of former veterinary practice

May we request a transfer of records?

Yes
No

Would you like us to call you for your appointment?

Yes
No

Reasons or conditions that prompted your visit?

Special requests or conditions?

Please list any additional pets here

Please read the following:*

I agree

I understand, by indicating I agree and submitting this registration, that I am responsible for any charges incurred by my pet while in the care of the doctors at Best Friends Pet Clinic and that charges are due and payable at the time of service, unless other arrangements are made in advance. Any balance that is carried over a period of 30 days will accrue a monthly finance charge of 1.5% or 18% per annum. Any balance that I leave unpaid will be forwarded to Best Friends Pet Clinic's collection agency, and will incur a 25% collection fee for which I am liable, in addition to monthly finance charges.