New Client Form

Dr.       Mr.         Mrs.        Miss          Ms.

Owner's First and Last Name:         

Co-Owner's First and Last Name:  

Street Address:     
City:           State:         Zip

Home Phone # (with area code):      

Occupation:                                      

Employer:                                          

Work Phone # (with area code):      

Cell Phone # (with area code):         

E-mail Address:                                

Pet Information

Pet Name:
 
Type of Pet:
Breed:
Color:

Gender:
Spayed/Neutered:
Date of Birth:

Is This Pet's Vaccines Current?      Yes      No     Not Sure

Do you have pets medical records?     Yes     No


Second Pet:
 
Type of Pet:
Breed:
Color:

Gender:
Spayed/Neutered:
Date of Birth:

Is This Pet's Vaccines Current?      Yes      No     Not Sure

Do you have pets medical records?  Yes       No


Third Pet:
 

Type of Pet:
Breed:
Color:

Gender:
Spayed/Neutered:
Date of Birth:

Is This Pet's Vaccines Current?      Yes      No     Not Sure

Do you have pets medical records?  Yes No

Are there medical records for your pet(s) at another Veterinary Practice?

Yes    No


Name of Former Veterinary Practice?

May we request a transfer of records?

Yes    No


How did you learn about us?

Phone Book           Internet Search/Web site         Location

SPCA                     Breeder                                    I am a Former Client   

 Pet Store (name):                              

Dr. Referral,  (If so, who?):               

Friend or relative (If so, who?):        

Other (Please specify):                       

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 Georgetown Animal Clinic, P.C. and that charges are due and payable at the time of service, unless other arrangements are made in advance. Any balance that is carried over a period of 30 days will accrue a monthly finance charge of 1.5% or 18% per annum. Any balance that I leave unpaid will be forwarded to Georgetown Animal Clinic, P.C. collection agency, and will incur a 25% collection fee for which I am liable, in addition to monthly finance charges.

I have read this statement and I agree
I do not agree		 .


WE ACCEPT THE FOLLOWING: CASH, CHECK, MASTER CARD,
VISA, AMERICAN EXPRESS, DISCOVER. 
WE CAN ARRANGE FOR CARE CREDIT, ASK OUR RECEPTIONIST FOR DETAILS.

If there is anything else you would like to tell us, please enter your comments here: