New Client Form

Client and Contact
First and Last Name
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Home Phone*
Cell Phone*
Email*
DOB*
How did you become aware of this clinic?
Choose one*
If other, please specify
If another client, please specify who referred you
Emergency Contact Person*
Home Phone*
Cell Phone*
Name of Previous Veterinarian
Phone of Previous Veterinarian
Pet Information

Pet 1
Pet 1 Name*
Sex*
Species*
Breed*
Color*
DOB*
Pet 2 (optional)
Pet 2 Name
Sex
Species
Breed
Color
DOB
Pet 3 (optional)
Pet 3 Name
Sex
Species
Breed
Color
DOB
Our Fee Policy*
I understand that all fees are due at time of service. We accept Cash, Checks, Debit, Visa, MasterCard, American Express, Discover, CareCredit, Apple Pay, Trupanion, and Trupanion Express. If you are in need of alternative payment arrangements please discuss that prior to completion of services.*
Yes, I understand the fee policy.
Consent*
I hereby authorize the veterinarian to examine, prescribe for or treat the above described pet(s). I understand that all animals must be current on vaccinations and testing for boarding, grooming, daycare and hospital procedures. I assume all responsibility for all charges incurred in the care of my animals. I also understand that these charges will be paid for at the time of release and that a deposit may be required for surgical treatments or hospitalization.  

Photo Release: I agree that Amity Woods Animal Hospital and Lodge may use such photographs of me and/or my pet(s) with or without my name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising, web content, or social media sites.  I have read the above statement and by submitting this form, I understand and agree to the conditions above.*
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Email
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Client and Contact

How did you become aware of this clinic?

Pet Information

Pet 1

Pet 2 (optional)

Pet 3 (optional)