Clyde Park Veterinary Clinic

New Client Check In

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

Name & Email (required)
First Name (required)
Last Name (required)
Address (required)
Street Address (required)
City (required)
State/Province (required)
Zip/Postal Code (required)
,
Daytime Phone (required)
Phone TypePhone Number (required)
Evening Phone (required)
Phone TypePhone Number (required)
E-Mail Address :
How did you hear about us? If recommended, whom may we thank?

Pet's Name (required)

Age: Years, Months

Type of Pet (required) :
Breed:

Color/markings:

Sex: (required)
Male
Female

Neutered/Spayed
Neutered
Spayed

Are your pets vaccines current?
Do you have pets medical records?
Medical records at another veterinary Practice?
Yes
No

Name of Former Veterinary Practice

May we request a transfer of records?
Yes
No

Would you like us to call you for your appointment?
Reasons or conditions that prompted your visit?

Is your pet currently on any medications?

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 Clyde Park Veterinary Clinic and that CHARGES ARE DUE AND PAYABLE AT THE TIME OF SERVICE. We will gladly prepare a written estimate if you desire. In instances of extensive medical or surgical procedures where full payment may be difficult at discharge, we accept Care Credit, Visa, Mastercard, and Discover, or can, as a last resort, establish a payment agreement if approved prior to treatment. There will be a $35 service charge for any returned check. Any balance that I leave unpaid will be forwarded to Clyde Park Veterinary Clinic's collection agent, and will incur a collection fee for which I am liable, in addition to monthly finance charges. To prevent the spread of infectious diseases, and for the protection of our other patients, all hospitalized pets must be current on vaccines and free from internal and external parasites. By indicating that I agree below, I authorize this minimum level of preventative care and the appropriate charges will be assessed in the discharge invoice.
Must be 18 years or older to submit this form.
I have read this statement and - (required)
I Agree
I Disagree


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