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Farmingdale-NewClientForm

New Client Registration Form
This question requires a valid date format of MM/DD/YYYY.
calendar
This question requires a valid email address.
We respect your right to privacy.
When you supply your contact information, you will only receive approved communications
from Farmingdale Dog and Cat Clinic authorized vendors and service providers. 
Species
Gender
Neutered/Spayed?
Vaccines given in the past year?
Is your pet on medication?
How did you hear about us?
Payment in full is required at the time of services rendered or at discharge. We accept cash, checks, Visa, MasterCard, American Express, and CareCredit. Returned checks are subject to a $20 service fee and delinquent accounts are subject to accrued finance fees and turned over to a collection agency.
The undersigned has read as well as understands the above and will assume responsibility for all feeds associated with their pet's visit. *This question is required.
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