Forms : New Client

New Client Check In

Please help us to expedite your check in by completing and submitting this form before your first appointment.

Thank you for your cooporation in letting us assist you.

Form - New Client

Name: (required)
First Name (required)
Last Name (required)
Spouses Name:
First Name
Last Name
Address: (required)
Street Address (required)
City (required)
State/Province (required)
Zip/Postal Code (required)
,
E-mail address
E-Mail Address: (required) :
Primary Phone: (required)
Phone TypePhone Number (required)
Secondary Phone: (required)
Phone TypePhone Number (required)
How did you find us?
How did you first hear about us?
This Website
Location
Yellow Pages
Referral
Homeowners Association News Letter

Is there someone we may thank for referring you?

First Pet
Pet's Name:

Date of Birth or Approximate Age:

Species of Pet:
Canine
Feline

Breed:

Color or description:

Sex:
Male
Female

Neutered/Spayed:
Neutered (altered male)
Spayed (altered female)

Is your pet current on vaccinations?
Yes
No
I don't know

Does your pet have any major health problems?

Is your pet on any medications or special diets?

Does your pet have any allergies? (ex. medications, vaccine reactions, foods)

Second Pet
Pet's Name

Date of Birth or Approximate Age

Species of Pet
Canine
Feline

Breed

Color or description

Sex:
Male
Female

Neutered/Spayed
Neutered (altered male)
Spayed (altered female)

Is your pet current on vaccinations?
Yes
No
I don't know

Does your pet have any major health problems?

Is your pet on any medications or special diets?

Does your pet have any allergies? (ex. medications, vaccine reactions, foods)

If you have additional pets, list their names and we will collect more information in the office.

Medical Records
Name of Former Veterinary Practice

May we request a transfer of records?
Yes
No

I authorize release of medical records to other veterinary hospitals when requested. (required)
I agree
I disagree

I authorize release of vaccination records to boarding facilities or groomers when requested. (required)
I agree
I disagree

Would you like us to contact you to schedule an appointment? (required)
Yes
No

Reason for requested visit:

Special requests?

Please Read
Financial Responsibility
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 Custer McDermott Animal Hospital. I understand that all charges are due and payable at the time of service, unless prior arrangements have been made. 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 Custer McDermott Animal Hospital's collection agency.
I have read this statement and - (required)
I agree

Estimates
We will gladly prepare a written estimate of expected charges any time if requested. Estimates are made in good faith. Unforseen costs do occaisionally occur and will be the responsibility of the client. If you would like an estimate prepared, please do not hesitate to ask.
Payment forms accepted:
We accept Cash, checks (except on first visit), Visa, Mastercard, Discover, and American Express and Care Credit.

The verification code below ensures the form is not submitted by a computer
Verification Code :
Enter the code you see in the graphic below in this box.
Your post will not be allowed if you do not type this in correctly.