New Client Form – Mill Creek Veterinary Hospital

Welcome to Mill Creek Veterinary Hospital. Thank you for giving us the opportunity to care for your pet. Please help us meet your needs better by taking a moment to complete this information sheet for our records.

Client Information

Owner's Name:

Spouse:

Mailing Address:

City:

State:

Zip:

Country:

Home Phone:

Cell Phone:

Place of Employment:

Work Phone:

E-Mail Address

Additional Phone Number:

Additional Information

How did you hear of our hospital?

Hospital SignCommunity AdvertisingYellow PagesWebsiteInvidual

If an individual, someone we may thank?

Payment Information

Payment is due when services are performed. We will gladly prepare an estimate if desired. If you ever plan on paying by check or credit/debit card, please complete the following. If you choose not to complete the following, you will be placed on a “CASH ONLY” basis. All returned checks will be charged a $35.00 returned check fee.

Date of Birth:

Driver License Number:

State:

Statement of Ownership and consent

By signing this document, I confirm that the above information is correct. I also confirm that I am the owner of all animal(s) listed on my account, or have written authorization from the owner to consent to treatment from Mill Creek Veterinary Hospital. I hereby authorize the performance of professionally accepted diagnostic, therapeutic, anesthetic, and surgical procedures necessary for its treatment. To prevent the spread of infectious disease and parasites, hospitalized animals must be current on all vaccines, free of internal and external parasites. I authorize the treatment of vaccines and parasite control as needed for my animal. I accept financial responsibility for all services incurred. I also understand that charges will be paid at the time of service.

Date: