New Client Form - Alpine Hospital For Animals

Blank Form (#4)

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. If it is easier you can instead feel free to print our New Client Form to fill out and bring with you. Thank you for your cooperation in letting us assist you.

First Name

Last Name

Email Communication

Help us go green by allowing email contact (we won't abuse it). Uncheck if you prefer paper.

Spouse, Partner, or Significant Other

First Name

Last Name

Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Daytime Phone

Evening Phone

How did you hear about our hospital?

If referred, who may we thank?

Pet's Name

Age: Years, Months

Breed

Gender

Male

Female

Neutered / Spayed

Neutered

Spayed

Please list any additional pets here

Are your pets vaccines current?

Yes

Do you have pets medical records?

Yes

Medical records at another veterinary practice?

Yes

Name of former veterinary practice?

May we request a transfer of records?

Yes

Would you like us to call you for your appointment?

Yes

Reasons or conditions that prompted your visit?

Special request or conditions?

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 Alpine Hospital for Animals and that charges are due and payable at the time of service. 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 Alpine Hospital for Animals's collection agency, and will incur a collection fee for which I am liable, in addition to monthly finance charges.

I have read this statement and I agree:

Yes

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