New Client Form - Acton Animal Hospital

Owner Name*

First Last

Date*

Address*

Street Address Address Line 2 City State ZIP Code

Email Address*

We use your email for appointment reminders, follow up check- ins and other relevant information

Phone*

Secondary ( Co- owner) Name:

First Last

Secondary Email

Secondary Phone

How did you hear about our hospital?

If referred, by whom?

Previous Veterinary Hospital*

Have you already submitted your previous medical records to our hospital?*

Yes
No

If so, when*

Pet Information

Name of Pet*

Species*

Dog
Cat

Birthdate*

Breed*

Color*

Sex*

Male
Male Neutered
Female
Female Spayed

Does your pet have any allergies to vaccines or medications?*

Yes
None Known

Please briefly describe your pets diet:*

We interact with social media, do we have your permission to use photos taken in our hospital of your pets?*

Yes
No

Terms of Service

Our goal is to serve you and your pet in every way possible, however, we do not offer billing. If the services that we provide do not fit into your budget, please ask for an estimate before services are provided. We do require payment in FULL at the time services are rendered. We accept Cash, VISA, Mastercard, American Express and Care Credit as forms of payment. Unfortunately, we are NOT accepting personal checks.

Terms of Service*

I understand

Appointment Cancellation Policy

Please be aware that if you are more than 15 minutes late for your scheduled appointment time, your appointment will be rescheduled. This is to ensure that the doctor does not fall behind on any scheduled appointments throughout the day and able to provide the appropriate medical care to all our patients equally. If you provide more than 3 no-call/no-show appointments, you will be re-booked to our next available appointment in the future. You will be unable to book same day, or last-minute appointments.

Cancellation Policy*

I understand

We thank you in advance for abiding by these policies and understand that we created these policies for all clients and patients to have the same medical experience when seen in our office.

All information I have provided is accurate. I have read the Terms of Service and understand these policies.

Signature*