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 & Email (required)
First Name (required)
Last Name (required)
Address (required)
Street Address (required)
City (required)
State/Province (required)
Zip/Postal Code (required)
,
Daytime Phone (required)
Phone TypePhone Number (required)
Evening Phone (required)
Phone TypePhone Number (required)
E-Mail Address :
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
PROFESSIONAL FEES ARE TO BE PAID AT THE TIME SERVICES ARE RENDERED. - I agree to pay for services rendered by Eagle Fern Veterinary Hospital, PC. I assume full financial responsibility for all charges incurred by my pet. - It is understood that first time clients are asked to pay cash, debit card or credit card. Thereafter, checks are accepted as a form of payment. - It is understood that there will be a $25.00 fee for returned checks. - It is understood that an estimate of charges will be given for services. Charges may exceed a given estimate if complications arise. I will be contacted prior to treatment, if possible, should complications occur. - Further, I understand that a deposit of 50% may be required before services are performed. - If this account is referred to an agency or attorney for collection, I agree to pay attorney's fees and cost as may be allowed by law, whether or not a lawsuit is filed.
I have read this statement and -
I Agree
I Disagree


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