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)
Spouse
First Name
Last Name
Address (required)
Street Address (required)
City (required)
State/Province (required)
Zip/Postal Code (required)
,
Daytime Phone (required)
Phone TypePhone Number (required)
Evening Phone (required)
Phone TypePhone Number (required)
E-Mail Address :
Pet's Name (required)

Age: Years, Months or Birthday

Type of Pet (required) :
Breed:

Color:

Sex: (required)
Male
Female

Neutered/Spayed
Neutered
Spayed

Do you currently have an appointment? (required)
Yes
No

Would you like us to call you for your appointment
Are your pet's vaccines current?
(If yes, please contact your previous veterinarian to have records faxed to us or bring them with you to your next appointment.)
Yes
No

Reasons or conditions that prompted your visit?

Special requests or conditions?

Prior Medical Problems

Pet's Current Medications

Describe your Pet's Diet

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 mccordsvillevethospital 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 mccordsvillevethospital'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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