New Client Form

Client Date of Birth

Employer:

Occupation:

Driver's License#:

Co-Owner Name (first & last):

Co-Owner Phone Number:

Do you qualify for senior or military benefits?

yes - senior benefits

yes - military benefits

no

Pet's Name

Age / DOB

Species

Breed

Color

Sex

Female Intact

Female Spayed

Male Intact

Male Neutered

Microchip Number

Pet's Name

Age/DOB

Species

Breed

Color

Sex

Female Intact

Female Spayed

Male Intact

Male Neutered

Microchip Number

Do you have a previous Veterinarian?

yes

no

If you answered yes, to the previous question, we will be happy to contact your previous veterinarian for your pet's health records.

Please provide your Previous Veterinarian and Phone Number:

You may also chose to email us your pet's health records at: WSVC@yourvetdoc.com

How did you hear about us?

Internet Search

Website

Yelp

Yellow Pages

Drive By

Client Referral

Other

If you were referred by a client, what is their name?

I understand that my pet’s picture may be used on social media sites.

YES, you can use my pet's photo on social media.

NO, do not use my pet's photo on social media.

Reason for your pet's visit:

Please note: All fees incurred at Washington Square Veterinary Clinic are expected to be paid upon the release of your pet. There is a $35 charge for each returned check. We accept CareCredit and Scratchpay

I have read and understand the payment policy:*

Name:
Date:

Preferred Payment Method (indicate one or two)

Visa

MasterCard

Discover

AMEX

Debit

Cash

Check

I hereby authorize the doctors at Washington Square Veterinary Clinic to receive, prescribe for, or operate upon my pet animals when presented by myself or my agent.

The doctors and staff at Washington Square Veterinary Clinic are to use all reasonable precautions against injury, escape, or destruction of my animals, but they will not be held liable for any problems that might arise from the care, treatment, or safe-keeping of the animals as it is understood that I, as the owner, assume all the risk.

If an animal is not picked up within fourteen (14) calendar days after the animal was due to be picked up, it will be considered abandoned and will become the property of Washington Square Veterinary Clinic. Every effort will be made at that time to find a new home for the animal. It is understood that such abandonment does not relieve me from paying for the cost of all services rendered and the use of the clinic, including the fees for boarding.

I have read the foregoing and agree.*

Name:
Date:

New Client Form

Client Date of Birth

Employer:

Occupation:

Driver's License#:

Co-Owner Name (first & last):

Co-Owner Phone Number:

Do you qualify for senior or military benefits?

Patient Information:

Pet's Name

Age / DOB

Species

Breed

Color

Sex

Microchip Number

Pet #2

Pet's Name

Age/DOB

Species

Breed

Color

Sex

Microchip Number

General Information

Do you have a previous Veterinarian?

If you answered yes, to the previous question, we will be happy to contact your previous veterinarian for your pet's health records.

Please provide your Previous Veterinarian and Phone Number:

You may also chose to email us your pet's health records at: WSVC@yourvetdoc.com

How did you hear about us?

If you were referred by a client, what is their name?

I understand that my pet’s picture may be used on social media sites.

Reason for your pet's visit:

Billing Information

Please note: All fees incurred at Washington Square Veterinary Clinic are expected to be paid upon the release of your pet. There is a $35 charge for each returned check. We accept CareCredit and Scratchpay

I have read and understand the payment policy:*

Preferred Payment Method (indicate one or two)

New Client Form

Client Date of Birth

Employer:

Occupation:

Driver's License#:

Co-Owner Name (first & last):

Co-Owner Phone Number:

Do you qualify for senior or military benefits?

Patient Information:

Pet's Name

Age / DOB

Species

Breed

Color

Sex

Microchip Number

Pet #2

Pet's Name

Age/DOB

Species

Breed

Color

Sex

Microchip Number

General Information

Do you have a previous Veterinarian?

If you answered yes, to the previous question, we will be happy to contact your previous veterinarian for your pet's health records. Please provide your Previous Veterinarian and Phone Number:

You may also chose to email us your pet's health records at: WSVC@yourvetdoc.com How did you hear about us?

If you were referred by a client, what is their name?

I understand that my pet’s picture may be used on social media sites.

Reason for your pet's visit:

Billing Information

Please note: All fees incurred at Washington Square Veterinary Clinic are expected to be paid upon the release of your pet. There is a $35 charge for each returned check. We accept CareCredit and Scratchpay I have read and understand the payment policy:*

Preferred Payment Method (indicate one or two)

If you answered yes, to the previous question, we will be happy to contact your previous veterinarian for your pet's health records.

Please provide your Previous Veterinarian and Phone Number:

You may also chose to email us your pet's health records at: WSVC@yourvetdoc.com

How did you hear about us?

Please note: All fees incurred at Washington Square Veterinary Clinic are expected to be paid upon the release of your pet. There is a $35 charge for each returned check. We accept CareCredit and Scratchpay

I have read and understand the payment policy:*