New Client Form Step 1 of 3 33% Owner Name* Co-Owner Name Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email Address Home Number Work Number Cell Number* Co-Owner Work Number Co-Owner Cell Number Appointment Scheduled?YesNoDate and time of appointment (if scheduled) Name of Previous Clinic Phone Military Yes No Senior Yes No Place of Employment Work No. I authorize Park Animal Hospital to care/diagnose/treat my pet.* I Agree I hereby agree to be financially responsible for any and all charges incurred at Park Animal Hospital* I Agree I understand that payment is due at the time services are rendered* I Agree I understand that emergencies, surgeries, and anticipated large bills will require a deposit.* I Agree I understand that Park Animal Hospital does not accept the following: Checks for OVER $100.00, Business checks, Out of state checks, American Express* I Agree I understand that a $25.00 fee will be charged for any check returned unpaid by my bank. I also understand that Park Animal Hospital does not re-submit returned checks and that if not paid with either cash or credit card within 10-days from the date returned, the check will be turned over to the District Attorney’s office for legal action* I Agree I understand that Park Animal Hospital does not do any billing. However they do offer CareCredit on approved credit.* I Agree I understand in order to prevent the spread of infectious diseases and parasites, ALL hospitalized, boarded or groomed pets must be current on vaccines and dewormings.* I Agree I agree to allow Park Animal Hospital to place my pet’s photo in their website photo gallery* I Agree I was referred to Park Animal Hospital (check one)* Drive-By Yellow Pgs Internet Recommended by Whom? First PetSelect One:* Dog Cat Exotic Type of exotic Pet InformationNameBreedMicrochip#Date of BirthColorSexSpayed or NeuteredDate of VaccinationsRabiesDA2PParvoCoronaBordatella Date of VaccinationsRabiesFELVENT-FVRCPFIP Where did you purchase/adopt your pet from?* Current diet:* Any other health history we should be aware ofSecond PetSelect One: Dog Cat Exotic Type of exotic Pet InformationNameBreedMicrochip#Date of BirthColorSexSpayed or NeuteredDate of VaccinationsRabiesDA2PParvoCoronaBordatella Date of VaccinationsRabiesFELVENT-FVRCPFIP Where did you purchase/adopt your pet from? Current diet: Any other health history we should be aware ofThird PetSelect One: Dog Cat Exotic Type of exotic Pet InformationNameBreedMicrochip#Date of BirthColorSexSpayed or NeuteredDate of VaccinationsRabiesDA2PParvoCoronaBordatella Date of VaccinationsRabiesFELVENT-FVRCPFIP Where did you purchase/adopt your pet from? Current diet: Any other health history we should be aware of Please be advised that there is not overnight supervision at Park Animal Hospital by a veterinarian or veterinary technician. If the doctor feels that there is a significant risk or there is a necessity for overnight supervision you will be advised accordingly of the risks vs benefits. We are not affiliated with the emergency hospitals and are not in control of their charging policies. It is always your right to elect to take your pet for overnight supervision at additional cost. Unforeseen incidents may and can happen but are uncommon.Beginning July 1, 2008, Park Animal Hospital is implementing a “NO SHOW” POLICY. - For Routine and Grooming appointments, a 4 hour notice of cancellation is required. -- A $20. 00 NO SHOW CHARGE will be applied to your account if proper notice is not given. - For Surgical Procedures, a 24 hour notice of cancellation is required. -- A $50.00 NO SHOW CHARGE will be applied to your account if proper notice is not given. I have read and understand the above policies. Type Signature EmailThis field is for validation purposes and should be left unchanged.
