New Clients Form

Owner Name*
Owner Phone Number*
Owner Work Phone Number
Co-Owner Name
Co-Owner Phone Number
Co-Owner Work Number
Address*
Street Address Address Line 2 City State ZIP Code
Email Address*
Name of Previous Clinic
Phone
Military
Senior
Recommended by Whom?
Place of Employment
May we contact your previous Veterinarian for your pet's history?
- Yes
- No
Previous Veterinarian Name and Phone Number

First Pet
Select One:*
- Dog
- Cat
Pet Information
Name Breed Microchip# Date of Birth Color Sex Spayed or Neutered
Date of Vaccinations
Rabies DA2P Parvo Corona Bordatella
Date of Vaccinations
Rabies FELV ENT-FVRCP FIP
Current Medications
Any serious illness or surgery
Any known allergies
Diet
Second Pet
Select One:
- Dog
- Cat
Pet Information
Name Breed Microchip# Date of Birth Color Sex Spayed or Neutered
Date of Vaccinations
Rabies DA2P Parvo Corona Bordatella
Date of Vaccinations
Rabies FELV ENT-FVRCP FIP
Current Medications
Any serious illness or surgery
Any known allergies
Diet
Third Pet
Select One:
- Dog
- Cat
Pet Information
Name Breed Microchip# Date of Birth Color Sex Spayed or Neutered
Date of Vaccinations
Rabies DA2P Parvo Corona Bordatella
Date of Vaccinations
Rabies FELV ENT-FVRCP FIP
Current Medications
Any serious illness or surgery
Any known allergies
Diet

Payment Options

Cash/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.
Type Signature
Thank you for your confidence in us. We appreciate the opportunity to serve you!
Name
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Appointments

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First Pet

Second Pet

Third Pet

Payment Options

Thank you for your confidence in us. We appreciate the opportunity to serve you!

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