New Client Form

Co-Owner Name (first & last):

Co-Owner Phone Number:

Pet's Name

Age / DOB

Species

Breed

Color

Sex

Female Intact

Female Spayed

Male Intact

Male Neutered

Previous Veterinarian and Phone Number

How did you hear about us? If referred by a partner business, please let us know so we can properly thank them.

Canine Republic

Woodland Park

2nd Family Dogs

Collin County Hospital

Google Maps

Search Engine

Facebook

Our Website

Digital Hospital Sign

Other

If you were referred by a client, what is their name?

I understand that my pet’s picture may be used on social media sites.

YES, you can use my pet's photo on social media.

NO, do not use my pet's photo on social media.

Reason for your pet's visit:

FEES ARE DUE AT THE TIME SERVICES ARE RENDERED
We will gladly prepare a written estimate if you desire. Estimates are made in good faith. We will do our best to stay as close as possible to estimated charges. Unpredictable costs do occasionally occur and will be the responsibility of the client. If you would like a written estimate prepared, please ask someone on our staff. We accept cash, Visa, MasterCard, Discover, American Express, and Care Credit®. Checks are not accepted on first visits. Checks will be accepted on subsequent visits with Texas Drivers License. No temporary checks will be accepted. A fee of $35.00 will be charged on all returned checks. It is your responsibility to update your account in the event of a returned check. If arrangements are not made to update your account, we will send your returned check to the district attorney

I assume financial responsibility for services provided for my pet(s). Please provide your signature.*

I authorize the release of medical records to other veterinary hospitals when requested.*

Yes

No

I authorize release of vaccination records to boarding facilities when requested*

Yes

No

We will be able to provide better care for your pet if we are able to access their previous medical records. By signing below you are giving Custer McDermott Animal Hospital authorization to contact your pet's previous veterinarian and request a copy of their records. These records will be used for medical purposes only and will not be shared with any outside sources.

Please provide your signature.*