Georgetown Animal Clinic, PC

5155 Sheridan Drive
Williamsville, NY 14221

(716)633-7123

www.georgetownanimalclinic.com

New Client Form

PLEASE CALL OUR OFFICE AT 716-633-7123 PRIOR TO COMPLETING THIS FORM

Please email any medical records you may have to gacvets@gmail.com or fax to 716-633-8959

New Client Form

Owner's First and Last Name (required)

First Name (required)	Last Name (required)

Co-Owner's First and Last Name

First Name	Last Name

Dr.
Mr.
Mrs.
Miss
Ms.

Street Address (required)
Street Address (required)

City (required) ,	State / Province (required)	Zip / Postal Code (required)

Contact Telephone Numbers

Home Number (with area code) (required)

Work Number

Cell Number (required)

Employment Information

Occupation

Employer

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

Pet Information

Pet Name

Type of Pet (required)

Dog
Cat
Rabbit
Guinea Pig
Other

Breed (required)

Color (required)

Gender (required)

Male
Female
Unknown

Spayed/Neutered? (required)

Yes
No
Unknown

Date of Birth:

Are This Pet's Vaccines Current (required)

Yes
No
Not Sure

Do You Have This Pet's Medical Records (required)

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) (required)
Phone Book
Internet Search/Website
Location
SPCA
Breeder
I am a former client
Pet Store
Dr. Referral
Friend or Relative
Other

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.

If Pet Store, Dr. Referral, Friend or Relative, or Other Please provide name

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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