Cainhoy New Client Form

New Client Form

Client Information

First Name *This question is required.

Last Name *This question is required.

Spouse or Co-owner

Street Address *This question is required.

City *This question is required.

State *This question is required.

Zip

Home #

Cell #

Work #

Preferred Phone #

Email Address *This question is required. This question requires a valid email address.

We respect your privacy and greatly appreciate you sharing up-to-date contact information with us for the benefit of your pet's health. We will never sell or rent your email address or personal information to third parties and you will always be able to unsubscribe from email communications, which will focus on the following: due dates for vaccinations, exams, or other relevant services, and hospital news and specials or promotions.

Pet Information

Pet Name: *This question is required.

Species *This question is required.

Breed *This question is required.

Gender *This question is required.

Color *This question is required.

Spayed/Neutered? *This question is required.

Birth Date OR Approximate Age *This question is required.

Microchip (If Applicable)

Current on Vaccinations? *This question is required.

Where would we be able to obtain your pets' previous medical records? (list all that apply) *This question is required.

Hospital Name #1
Phone #1
Hospital Name #2
Phone #2
Hospital Name #3
Phone #3

Additional Comments/Concerns

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

PHOTO CONSENT: We love social media! Do we have your permission to share your pet(s)' image and story on social media, our website, and other forms of related media? Your name and personal information will never be shared. Simply check below to authorize this: *This question is required.

TREATMENT CONSENT: I hereby authorize the veterinarian to examine, prescribe for or treat the above described pet(s). I assume responsibility for all charges incurred in the care of this animal. I understand that payment is always due IN FULL at time of service and that a deposit may be required for hospitalization and surgical procedures. I recognize that financial concerns should be discussed PRIOR to examination and treatment. The Cainhoy Veterinary Hospital staff is happy to provide estimates. I understand that Cainhoy Veterinary Hospital does not bill. Acceptable methods of payment are cash, personal check, Visa, MasterCard, American Express, Discover, and CareCredit.

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