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New Client/Pet Information Form

If you have not visited our hospital before, you can expedite your first check-in by filling out and submitting this form to us ahead of time.

Pet owner's name

Owner's spouse/partner/co-owner

Address

All fees are due at the time services are rendered. If you wish to pay by check, credit card, bank, or debit card, please fill out the information below.

Pet Information

RABIES VACCINATIONS

Due to state law, all dogs and cats must be current on rabies vaccinations.

PAYMENT FOR SERVICES

For your convenience, we offer several payment methods: cash and all major credit cards. We will gladly prepare a written estimate for you. Please ask a receptionist, technician or doctor. Payment is due at the time services are rendered.

PLEASE READ THE FOLLOWING STATEMENT

I understand every effort will be made to achieve a successful outcome and to provide for all possible safety in hospital care and handling. I hereby authorize this hospital to receive, prescribe for, treat, or perform surgery upon the pet listed and additional pets I present. Furthermore, I agree to pay fees for services rendered at the time the pet is discharged from the hospital, or the service is otherwise terminated. I agree to pay for the reasonable costs of collection in the event that collection efforts become necessary. I understand that a service fee of $20.00 will be assessed for each non-sufficient fund check and/or certified letter that must be sent. If I neglect to pick up my pet within 5 days of the discharge date, and do not notify you within that time period, you may assume that he/she is abandoned. If such occurs, I fully understand that ownership will be designated to Stapleton Veterinary Hospital.