New Client Form

 

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 (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 Type Phone Number (required)
Evening Phone (required)
Phone Type Phone 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
Intact (not neutered or 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 appointmentReasons or conditions that prompted your visit?
Special requests or conditions?
Please list any additional pets here
Please Read
I understand, by indicating I agree and submitting this registration, that I am responsible for any charges incurred by my pet while in the care of the doctors at Advanced Pet Care of Parker and that charges are due and payable at the time of service, unless other arrangements are made in advance. Any balance that is carried over a period of 30 days will accrue a monthly finance charge of 1.5% or 18% per annum. Any balance that I leave unpaid will be forwarded to Advanced Pet Care of Parker’s collection agency, and will incur a 25% collection fee for which I am liable, in addition to monthly finance charges.I have read this statement and –
I Agree
I Disagree

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