New Client Form

Active Duty Military?*

Yes

No

Senior Citizen (62+)?*

Yes

No

Co-Owner Name (first & last):

Co-Owner Phone Number:

Pet's Name

Age / DOB

Species

Breed

Color

Sex

Female Intact

Female Spayed

Male Intact

Male Neutered

Previous Veterinarian and Phone Number

May we send you email and text appointment reminders and clinic communication?*

Yes

No

List of persons that are authorized to receive information about my pet(s):*

How did you hear about us?

Internet Search

Drive By

Client Referral

Other

If you were referred by a client, what is their name?

I understand that my pet’s picture may be used on social media sites.

YES, you can use my pet's photo on social media.

NO, do not use my pet's photo on social media.

Reason for your pet's visit:

Payments are expected in full at time of service. Estimates can be requested at any time. By acknowledging below, I am stating that I am the owner and/or authorizing agent of the animals presented to Belltowne Veterinary Center and I am requesting veterinary services by provided. I accept full responsibility for requesting, receiving and payment services. Payment is due at the time of service: We accept VISA/Mastercard, Discover, AMEXX, Care Credit, Scratch Pay. If I miss an appointment and/or cancel less than 24 hours prior to an appointment, a deposit will be required prior to scheduling future visits. The deposit may be used toward the visit; however, if I do not keep my appointment that deposit is non-refundable. Please sign your name below.*