Owner Name

Co-Owner Name

Address

Address Line 1

Address Line 2

City

State

Zip Code

Email

Home Number

Work Number

Cell Number

Co-Owner Work Number

Co-Owner Cell Number

Name of Previous Clinic

Previous Clinic Phone

How did you hear about us?

Other

Who may we thank? (Referral)

Do you already have your first appointment scheduled?

Yes
No

I give Elm Creek Animal Hospital permission to release rabies and other vaccine information when requested to authorities such as police, boarding and grooming facilities or rescue organizations.

Yes
No

I give Elm Creek Animal Hospital permission to release my pet's medical history when requested to other veterinary facilities.

Yes
No

I authorize Elm Creek Animal Hospital to release my name and/or phone number to the person finding my pet, in the case my pet should become lost or stolen.

Yes
No

First Pet

Select One

Dog
Cat
Other

Other

Pet Information

Name

Breed

Microchip

Age/Date of Birth

Color

Sex

Spayed or Neutered

Second Pet

Select One

Dog
Cat
Other

Other

Pet Information

Name

Breed

Microchip

Age/Date of Birth

Color

Sex

Spayed or Neutered

Third Pet

Select One

Dog
Cat
Other

Other

Pet Information

Name

Breed

Microchip

Age/Date of Birth

Color

Sex

I agree this statement

I/we hereby authorize the veterinarians to examine, prescribe for, or treat my pets (s). I/we assume full responsibility for all charges incurred in the care of this/these animal(s). I/we also understand that these charges will be paid in full at the time of release and that a deposit may be required for certain surgical treatments or other procedures.

Signature

Clear Signature

NewClient Form

New Client Form

First Pet

Pet Information

Second Pet

Pet Information

Third Pet

Pet Information

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