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New Patient Form

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New Patient Form

Please fill out this form as completely and accurately as possible so we can get to know you and your pet(s) before your visit. If this is an emergency, or if your pet needs urgent care, please call us at 440-708-2828 for a faster response.

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Name *

First

Last

Email *

Phone *

Address

Address Line 1

Address Line 2

City

State

Zip Code

Spouse/Significant Other's Name

First

Last

Spouse/Significant Other's Cell Phone

Spouse/Significant Other's Home Phone

Spouse/Significant Other's Email

Pet's Name *

Species *

Sex *

Male
Neutered Male
Female
Spayed Female

Breed *

Color *

Age/Birthdate *

Dates of last vaccines:

Distemper

Rabies

Panleukopenia

Hepatitis

Lymes

Bordetella

Parainfluenza

Leukemia

Calicivirus

Rhinotracheitis

Parvovirus

Leptospirosis

Any additional vaccines?

Where did you hear about us?

Payment is due in full at time of service. We accept cash, checks and all major credit cards. We offer Care Credit if you need a payment plan. We pledge to do our best to care for your pet's health needs. We ask that you accept the responsibility for charges incurred in this treatment and accept that payment is due when services are rendered. Should you have concerns regarding the cost of a treatment or item, please ask us for an estimate prior to us providing services. We are happy to answer questions regarding treatment options and cost.

Agreement Terms: Balances due over 30 days are subject to a minimum $3.00/month service fee or 1.5% per month (18% APR) (whichever is the greater amount). Returned checks will be charged a $15.00 returned check fee and may be debited from your account electronically. *

I have read and understand.

Signature of Owner *

Date *

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New Patient Form

New Patient Form

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