New Client Form

Primary Owner *

First Name

Last Name

Phone *

(###)

###

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Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Secondary Owner (partner, family member, friend, etc)

First Name

Last Name

Phone

(###)

###

####

Emergency contact

First Name

Last Name

Phone

(###)

###

####

Who is allowed to make medical decisions for your pets? *

Primary owner only

Primary and Secondary owner only

Primary owner, Secondary owner, and Emergency contact

I hereby authorize the veterinarian to examine, prescribe for, and treat my pets. I assume responsibility for all charges incurred in the care of my pets and understand that these charges must be paid at the time services are rendered. *

I have read and agree to the statement above

Owner’s Signature: X_________________________________________________ Date: ___________________ *

Please check this box before clicking submit