Georgetown Animal Clnic PC: New Client Form

Georgetown Animal Clinic, PC

5155 Sheridan Drive
Williamsville, NY 14221

(716)633-7123

www.georgetownanimalclinic.com

- 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.
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Georgetown Animal Clinic, PC is an AAHA Accredited Hospital

To see what it takes to be accredited and learn more about the standard of excellence, click here. 

Access your pet's records from your phone!

Our secure app gives you direct access to manage your pet's health 24/7. To learn more, click here.