Ark - New Client Form

New Client Form

Client Registration *This question is required.

Owner First Name

Owner Last Name

Email Address This question requires a valid email address.

Address

City

State

Zip Code

Home Phone

Cell Phone

Employer

Work Phone

May We Contact You Via Email or Text?

Please specify which:

Co-Owner Information

Co-Owner Name

Relation to Owner

Home Phone

Cell Phone

Employer

Work Phone

Emergency Contact *This question is required.

Name

Phone #

Can We Use Your Pet's Photo for Social Media? *This question is required.

How Did You Hear About Us? *This question is required.

Please enter an 'other' value for this selection.
Please enter an 'other' value for this selection.
Please enter an 'other' value for this selection.
Please enter an 'other' value for this selection.

Pet History *This question is required.

Name

Species

Breed

Color

Sex

Spayed/Neutered?

Age/Date of Birth

Are There Additional Pets You'd Like to List?

Pet History - Pet #2

Name

Species

Breed

Color

Sex

Spayed/Neutered?

Age/Date of Birth

Are There Additional Pets You'd Like to List?

Pet History - Pet #3

Name

Species

Breed

Color

Sex

Spayed/Neutered?

Age/Date of Birth

Are There Additional Pets You'd Like to List?

Pet History - Pet #4

Name

Species

Breed

Color

Sex

Spayed/Neutered?

Age/Date of Birth

Are There Additional Pets You'd Like to List?

Pet History - Pet #5

Name

Species

Breed

Color

Sex

Spayed/Neutered?

Age/Date of Birth

Authorization *This question is required.

I hereby authorize the veterinarian(s) to examine and provide medical/surgical treatment for the above described animal(s). I assume responsibility for all charges related to the care of this animal(s). I also understand that payment for these charges are due at the time of the animal’s release unless prior arrangements are made with Ark Veterinary Hospital & Urgent Care. In the unlikely event that I do not pay this bill when due, I understand a service fee of $3.00 and 1.5% of the outstanding balance will be charged to my account monthly if not paid in full. Balances over 60 days will be forwarded to a collection agency and I will be responsible for collection and attorney fees as the law allows.

Clear

Signature of