New Client Form





Client Name
First Name:*
Last Name:*
Significant Other
First Name:
Last Name:
Email:*
Home Address:
City:
State:
ZIP Code:
Primary Phone:*
Secondary Phone:
Employer:
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:*
Species:*
If Other:
Sex:
Breed (if known):
Color:
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?
Phone:
Do you authorize the release of your pet’s medical records to Summertree Animal & Bird Clinic?

  

Authorization to Provide Care

I confirm I am 18 years old (or older) and I am the owner (or authorized agent of the owner) for the pet listed above. With my signature, I authorize the veterinarians and staff of Summertree Animal and Bird Clinic to examine, treat, administer medications and perform diagnostics, surgical procedures, and/or to hospitalize my pet if the doctor(s) deem it necessary for the health, safety or well being of my pet. I understand that, except in dire emergencies, all treatments and procedures will be discussed with me prior to implementations and a written estimate will be provided upon request. I agree to assume responsibility for all charges incurred in the care of my pet(s), as well as reasonable attorney’s fees, court costs, and interest if the balance is sent for collection. I understand that full payment is due at the time services are rendered, and that Summertree Animal and Bird Clinic does not bill for services or provide payment plans for treatment. Payments must be made with cash, Visa, MasterCard, Discover, American Express, Care Credit or a Check pre-printed with your name and address. At least one picture identification (driver’s license, etc) is required if you pay by credit card, check or Care Credit. Pre-payment of services may be required for medical concern cases or anesthetic procedures.

I acknowledge that I have read, understand and agree with the above information.

Check to confirm submission.

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