<p align="center"><font size="6"><strong><font color="#0000cc" face="Bookman Old Style">
Georgetown Animal Clinic, PC</font></strong></font><strong><font color="#0000cc" face="Bookman Old Style" size="5"><br />
<font size="2">5155 Sheridan Dr.</font><font size="2"><br />
Williamsville, NY 14221</font></font></strong><br />
<strong><font color="#0000cc" face="Bookman Old Style" size="5"><font size="2"></font><strong><em><font color="#ff0000"><font color="#0000ff" size="4">(716) 633-7123</font></font></em></strong></font></strong><br />
<strong><font color="#0000cc" face="Bookman Old Style" size="5"><strong><em><font color="#ff0000">See the difference</font></em></strong></font></strong></p><br />

Georgetown Animal Clinic, PC
5155 Sheridan Dr.
Williamsville, NY 14221

(716) 633-7123
See the difference


Form - - New Client


Dr.
Mr.
Mrs.
Miss
Ms.


Owner's First and Last Name (required)
First Name (required)
Last Name (required)
Co-Owner's First and Last Name
First Name
Last Name
Street Address
Street Address
City
State / Province
Zip / Postal Code
,
Contact Telephone Numbers
Home Number (with area code) (required)

Work Number

Cell Number

Employment Information
Occupation

Employer

E-Mail Address (required to access pet records on-line) :
Pet Information
Pet Name

Type of Pet
Dog
Cat
Bird
Rabbit
Guinea Pig
Other


Breed

Color

Gender
Male
Female
Unknown


Spayed/Neutered?
Yes
No
Unknown


Date of Birth:

Are This Pet's Vaccines Current
Yes
No
Not Sure


Do You Have This Pet's Medical Records
Yes
No


Second Pet (or scroll to 'other information' below)
Pet Name

Type of Pet
Dog
Cat
Bird
Rabbit
Guinea Pig
Other


Breed

Color

Gender
Male
Female
Unknown


Spayed/Neutered?
Yes
No
Unknown


Date of Birth

Are This Pet's Vaccines Current
Yes
No
Not Sure


Do You Have This Pet's Medical Records
Yes
No


Third Pet (or scroll to 'other information' below)
Pet Name

Type of Pet
Dog
Cat
Bird
Rabbit
Guinea Pig
Other


Breed

Color

Gender
Male
Female
Unknown


Spayed/Neutered?
Yes
No
Unknown


Date of Birth

Are This Pet's Vaccines Current
Yes
No
Not Sure


Do You Have This Pet's Medical Records
Yes
No


Other Information
Are There Medical Records For Your Pet (at another veterinary practice)
Yes
No


Name of Former Veterinary Practice

Street Address
Street Address
City
State / Province
Zip / Postal Code
,
Phone (if known)

May We Request a Transfer of Records
Yes
No


How Did You Learn About Us? (check all that apply)
Phone Book
Internet Search/Website
Location
SPCA
Breeder
I am a former client
Pet Store
Dr. Referral
Friend or Relative
Other
If Pet Store, Dr. Referral, Friend or Relative, or Other Please provide name


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 (required)
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


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