New Client Registration – Mainland Emergency Animal Clinic

Owner's Name:

Co-Owner Name:

Address:

City:

Postal Code:

Home Phone:

Cell Phone:

Co-owner phone

Email:

Previous Veterinary Hospital

Do you have pet insurance?

Insurance Company

Policy/ Customer #

#1 Pet's Name

Species

Breed

Sex

Female Male

Color

Are they Spayed or Neutered?

Yes No

Date Of Birth

Are their vaccines up to date?

Yes No

Does your pet have any known health conditions or allergies?

#2 Pet's Name

Species

Cat Dog Other

Breed

Sex

Female Male

Color

Are they Spayed or Neutered?

Yes No

Date Of Birth

Are their vaccines up to date?

Yes No

Does your pet have any known health conditions or allergies?

#3 Pet's Name

Species

Cat Dog Other

Breed

Sex

Female Male

Color

Are they Spayed or Neutered?

Yes No

Date Of Birth

Are their vaccines up to date?

Yes No

Does your pet have any known health conditions or allergies?

Date

I hereby acknowledge and agree to the terms and conditions set forth. By signing below, I confirm my acceptance and understanding of these terms.

Financial Agreement and Authorization of Treatment: I authorize the above-named pet(s) and agree, irrevocably, that in the consideration of the services to be rendered, I hereby obligate myself to pay the account in accordance with the regular rates and terms of the provider.

As required by law, you are hereby notified that a negative credit report reflecting your credit may be submitted to a credit reporting agency if you fail to fulfill the terms of your credit obligations to our establishment. Should the account be referred to an attorney or collection agency for collection, the undersigned agrees to pay actual attorney's fees and collection expenses.

A DEPOSIT MAY BE REQUIRED, AND FINAL BILLS ARE UPON RELEASE OF THE PATIENT. NO BILLING OR PAYMENT PLANS.

By clicking SUBMIT you consent to receiving SMS messages from Mainland Emergency Animal Clinic. Messages and Data rates may apply. Message frequency will vary. Reply Stop to Opt-out of messaging. Reply Help for Customer Care Contact Information. I have read and acknowledged the Privacy Policy.

Signature Of Owner

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