New Client Form

Client Name
First Name:*
Last Name:*
Significant Other
First Name:
Last Name:
Home Address:
ZIP Code:
Primary Phone:*
Secondary Phone:
Work Phone:
Please tell us how you found our clinic:
If Other:
Which Internet site or search engine?
Is there someone we can thank for this referral?
Can you provide the name of the Veterinary referral?
Can you provide the name of the Pet Store that referred you?
Payment is due as services are rendered. Payment is accepted in the form of CASH, VISA or MASTERCARD, or personal check (a valid Texas Driver’s license is required). New client / new patient medical concern cases will require a deposit (cash or credit card only) in advance of medical treatment. To avoid misunderstandings, we urge you to discuss all fees with the doctor before services are performed.

I have read and agree to the payment policy. I understand that payment in full will be due at the time services are performed, or before my pet leaves the hospital.

Patient Information

Patient Name:*
Date of Birth or Age of pet:*
If Other:
Breed (if known):
Has your dog/cat been vaccinated?
Date of Last Vaccinations:
Has your dog/cat been spayed/neutered?
Date of Spay/Neuter:
Is your dog/cat currently on heartworm preventative?
What is your pet’s main diet, including treats?
Does your pet have any drug allergies or special problems we should know about? If so, please specify:
Who is your pet’s previous veterinarian?
Do you authorize the release of your pet’s medical records to Summertree Animal & Bird Clinic?

Check to confirm submission.

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