PLEASE PRINT OUT THIS FORM, COMPLETE IT AND BRING IT IN WITH YOU ON YOUR FIRST VISIT TO OUR CLINIC
DOING SO WILL HELP US TO HELP YOU MORE QUICKLY
WELCOME TO THE NORTHEAST VETERINARY CLINIC
915.755.2231
Client Information: (Please Print)
FIRST NAME___________________________________ M.I._________ LAST NAME__________________________________
ADDRESS______________________________________ APPT____ CITY________________________STATE___ZIP______
PHONE #__________________________________________CELL/MESSAGE PHONE#________________________________
DRIVERS LICENSE____________________________ STATE_________ SSN________________________________________
***TO HELP PROTECT AGAINST CHECK AND CREDIT CARD FRAUD, WE MAY REQUIRE 2 FORMS OF I.D.***
EMPLOYER____________________________________ WORK PHONE____________________________ EXT____________
EMAIL ADDRESS:_____________________________________________________________EMAIL REMINEDERS: YES/NO
SECONDARY OWNER(S):__________________________________________________________________________________
***ONLY PERSONS LISTED ABOVE HAVE THE AUTHORITY TO CONSENT TO MEDICAL TREATMENT AND RECEIVE INFORMATION PERTAINING TO THE PETS LISTED ON THIS ACCOUNT. PAYMENT IS EXPECTED AT THE TIME OF SERVICE AND FROM THE INDIVIDUAL PRESENT AND CONSENTING TO TREATMENT***
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Previous Veterinarian or regular DVM_____________________________________________Phone____________________________
To prevent the spread of infectious diseases, all boarded and hospitalized patients need to be current on our required vaccines AND free from internal and external parasites
HOW DID YOU HEAR ABOUT US? NEVC WEBSITE______ YELLOW PAGES______ LOCALVETS.COM/YEXT.COM________SIGN__________
OTHER VET______________________ CLIENT_____________________________________FRIEND/RELATIVE___________
PAYMENT IS REQUIRED AT TIME OF SERVICES
HOW WILL YOU PAY TODAY? CASH______ CHECK______ VISA/MC______ DISCOVER______ AMEX______ CARE CREDIT________
I AUTHORIZE THE RELEASE OF VACCINE INFO ON MY PETS IF NEEDED, BY OTHER VETERINARIANS, GROOMERS, KENNELS, OR PROPER AUTHORITES: YES_____ NO ______
I HEREBY AUTHORIZE THE VETERINARIANS TO EXAMINE, PRESCRIBE FOR, OR TREAT THE ABOVE DESCRIBED PET(S). I ASSUME FULL RESPONSIBILITY FOR ALL CHARGES INCURRED IN THE CARE OF THE ANIMAL(S). I ALSO UNDERSTAND THAT ALL PROFESSIONAL FEES ARE DUE AT THE TIME SERVICES ARE RENDERED.
OWNER________________________________________________________________________________________________DATE________________________
OWNER________________________________________________________________________________________________DATE________________________
CLIENT ID___________________ ENTERED BY_____________________
