New Client Form

This form does not replace calling for an appointment. Please continue to call for an appointment or submit a request by clicking here.

Client and Contact
First and Last Name
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Home Phone*
Cell Phone*
Email*
DOB*
How did you become aware of this clinic?
Choose one*
If other, please specify
Emergency Contact Person*
Home Phone*
Cell Phone*
Name of Previous Veterinarian
Phone of Previous Veterinarian
Pet Information

Pet 1
Pet 1 Name*
Sex*
Species*
Breed*
Color*
DOB*
Pet 2 (optional)
Pet 2 Name
Sex
Species
Breed
Color
DOB
Pet 3 (optional)
Pet 3 Name
Sex
Species
Breed
Color
DOB
Our Fee Policy*
I understand that all fees are due at time of service. If you are in need of alternative payment arrangements please discuss that prior to completion of services.*
Yes, I understand the fee policy.
Consent*
I hereby authorize the veterinarian to examine, prescribe for or treat the above described pet(s). I understand that all animals must be current on vaccinations and testing for boarding, grooming, daycare and hospital procedures. I assume all responsibility for all charges incurred in the care of my animals. I also understand that these charges will be paid for at the time of release and that a deposit may be required for surgical treatments or hospitalization.  

Photo Release: I agree that Edgewood Animal Clinic may use such photographs of me and/or my pet(s) with or without my name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising, web content, or social media sites.  I have read the above statement and by submitting this form, I understand and agree to the conditions above.*
Accept

New Client Form

Client and Contact

How did you become aware of this clinic?

Pet Information

Pet 1

Pet 2 (optional)

Pet 3 (optional)