New Client Check In

If you would like to make an appointment, you can assist us to expedite your check in by submitting this form.

Thank you for your cooporation in letting us assist you.

Form - New Client

Name (required)
First Name (required)
Last Name (required)
Name (Spouse)
First Name
Last Name
Address (required)
Street Address (required)
City (required)
State/Province (required)
Zip/Postal Code (required)
,
County (required)

Daytime Phone (required)
Phone TypePhone Number (required)
Evening Phone (required)
Phone TypePhone Number (required)
E-Mail Address :
Place of Employment

Place of Employment (Spouse)

Work Phone (Spouse)
Phone TypePhone Number
Referred by:

Pet's Name (required)

Age: Years, Months

Type of Pet (required) :
Breed:

Sex: (required)
Male
Female

Neutered/Spayed
Neutered
Spayed

Are your pets vaccines current?
Do you have pets 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
Reasons or conditions that prompted your visit?

Special requests or conditions?

Please list any additional pets here

Please Read
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 Prairie View Animal Hospital and that charges are due and payable at the time of service. A monthly payment plan may be set up with a Doctor's approval. A payment agreement form must be completed and signed by the person financially responsible for the account. 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 for 120 days will be forwarded to Prairie View Animal Hospital's collection agency, and will incur a 33% collection fee for which I am liable, in addition to monthly finance charges. Monthly payments are required to keep the account current.
I have read this statement and -
I Agree
I Disagree


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