New Clients Form Step 1 of 3 33% Owner Name*Owner Phone Number*Owner Work Phone NumberOwner's Drivers License Number*Owner's Drivers License State Issued*Co-Owner NameCo-Owner Phone NumberCo-Owner Work NumberCo-Owner Drivers License NumberCo-Owner Drivers License State IssuedAddress* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email Address*Name of Previous ClinicPhoneMilitaryPlease SelectYesNoSeniorPlease SelectYesNoHow did you hear about us?Place of EmploymentMay we contact your previous Veterinarian for your pet's history?YesNo First PetSelect One:*DogCatPet InformationNameBreedMicrochip#Date of BirthColorSexSpayed or NeuteredDate of VaccinationsRabiesDA2PParvoCoronaBordatella Date of VaccinationsRabiesFELVENT-FVRCPFIP Current MedicationsAny serious illness or surgeryAny known allergiesDietSecond PetSelect One:DogCatPet InformationNameBreedMicrochip#Date of BirthColorSexSpayed or NeuteredDate of VaccinationsRabiesDA2PParvoCoronaBordatella Date of VaccinationsRabiesFELVENT-FVRCPFIP Current MedicationsAny serious illness or surgeryAny known allergiesDietThird PetSelect One:DogCatPet InformationNameBreedMicrochip#Date of BirthColorSexSpayed or NeuteredDate of VaccinationsRabiesDA2PParvoCoronaBordatella Date of VaccinationsRabiesFELVENT-FVRCPFIP Current MedicationsAny serious illness or surgeryAny known allergiesDiet Payment OptionsCash/Check: We accept payment by cash or check at the time of service. Bank Credit/Debit Card: We accept payment by MasterCard, Visa, Discover and American Express. In an effort to offer our clients more personalized financial arrangements, we are pleased to offer Care Credit and Scratch Pay. If you wish to take advantage of this payment plan, please ask one of our staff members for an application.I hereby authorize Foland Veterinary Services, PLLC to examine, prescribe and treat the above described pet(s) and any pet (s) presented by me now or in the future. I assume responsibility for any and all charges incurred during the care and or treatment of said pet(s). I also understand that these charges will be paid in full at the time my pet(s) are released back into my care. I also understand that a deposit may be required prior to any treatment and/or hospitalization through Foland Veterinary Services. All accounts that are not paid on as agreed are considered delinquent. All delinquent accounts will be charged a $50 service fee, plus any and all legal fees that may occur as the result of any expenses incurred in the collection of that debt.All payments are due at the time of services rendered. I have read and understand the above statements and agree to all terms therein I agree with the terms listed above. I grant Foland Veterinary Services permission to post my pet's picture, story, and medical information in print and/or on social media.*NoYesType SignatureThank you for your confidence in us. We appreciate the opportunity to serve you!CAPTCHANameThis field is for validation purposes and should be left unchanged.
