New Client Info

Client Information

First Name *

Last Name *

Address *

City *

State *

Zip Code *

Email *

Phone *

Were you referred by a family member or friend?

Yes

Please enter the name of who referred you.

Spouse or Co-Parent Name

Spouse or Co-Parent Phone

Spouse or Co-Parent Email

Alternate Emergency Contact Name

Alternate Emergency Contact Phone

Pet Information

Number of Pets *

Pet 1

Name *

Dog/Cat *

Dog

Cat

Breed *

Color/Markings *

Age or DOB *

Male/Female *

Male

Female

Unknown

Spayed/Neutered? *

Yes

Unknown

Microchip #

Pet 2

Name *

Dog/Cat *

Dog

Cat

Breed *

Color/Markings *

Age or DOB *

Male/Female *

Male

Female

Unknown

Spayed/Neutered? *

Yes

Unknown

Microchip #

Pet 3

Name *

Dog/Cat *

Dog

Cat

Breed *

Color/Markings *

Age or DOB *

Male/Female *

Male

Female

Unknown

Spayed/Neutered? *

Yes

Unknown

Microchip #

Pet 4

Name *

Dog/Cat *

Dog

Cat

Breed *

Color/Markings *

Age or DOB *

Male/Female *

Male

Female

Unknown

Spayed/Neutered? *

Yes

Unknown

Microchip #

Current Veterinarian

Would you like us to contact a previous vet for records for your pet?

Yes

Previous Clinic Name

I understand that Professional fees are to be paid at the time services are rendered. Park Veterinary Hospital is not in the business of advancing credit to its customer. All accounts will be billed monthly and all outstanding balances are due and payable when rendered. Any account which is not paid in full will be assessed a service charge of $7.50 or 1.5% of the unpaid balance, whichever is greater. If payment cannot be made in full Park Veterinary Hospital reserves the right to withhold your pet until payment is met at an additional charge of the nightly boarding rate. THERE IS A $350.00 SERVICE FEE FOR ANY ACCOUNT THAT MUST BE TURNED OVER TO OUR COLLECTION DEPARTMENT. In the event that suit is filed, venue will be Broward County, Florida. Furthermore, I agree that I will be held personally responsible for all costs associated with the collection of this account, including but not limited to: a collection agency fee and court costs. I also understand that all returned checks will be assessed a $35.00 service charge.

I have read and agree to the statement above.

Signature of Owner / Agent / Good Samaritan

Clear

Date

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Client Information

Pet Information

Pet 1

Pet 2

Pet 3

Pet 4

Current Veterinarian

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