New Client Registration

If you would like to make an appointment, you can assist us to expedite your check in by submitting this form.

Thank you for your cooporation in letting us assist you.

Form - New Client

Owner's Name (required)
First Name (required)
Last Name (required)
Spouse or other additional owner
First Name
Last Name
Address (required)
Street Address (required)
City (required)
State/Province (required)
Zip/Postal Code (required)
,
Home Phone (required)
Phone TypePhone Number (required)
Work Phone
Phone TypePhone Number
Cell Phone
Phone TypePhone Number
E-Mail Address :
Pet Information
Pet's Name (required)

Age: Years, Months

Type of Pet (required) :
Breed:

Sex: (required)
Male
Female
Unknown(exotics)

Neutered/Spayed
Neutered
Spayed
Neither

Are your pet's vaccines current?
Do you have pet's medical records?
Medical records at another veterinary practice?
Yes
No

Name of Former Veterinary Practice

Would you like us to call you to schedule an appointment?
How did you learn of our practice? Is there someone we may thank for referring you here?

Reasons or conditions that prompted your visit?

Special requests or conditions?

Please list any additional pets here

Please Read
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 the doctors at Country Court Animal Hospital and that charges are due and payable at the time of service, unless other arrangements are made in advance. 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 Country Court Animal Hospital's collection agency, and will incur a 25% collection fee for which I am liable, in addition to monthly finance charges.
I have read this statement and -
I Agree
I Disagree


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