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New Clients
About Us
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What To Expect
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Wellness Exams
New Pet Care Consults
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New Client Registration Form
Client Information
Primary Adult Owner's Name (Must be 18 or older, legally responsible for pet)
*
First
Last
Date of Birth (MM/DD/YYYY, required for dispensing certain medications)
*
Spouse/Partner/Other’s Name
*
First
Last
Their Cell #
*
Is this person allowed to make medical decisions regarding your pet(s)?
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Yes
No
Is there anyone in the home under the age of 18 that is considered to be the PRIMARY caretaker for an animal in your home? If yes, Name/Age/DOB and Animal cared for by this person.
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Address
*
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Cell Phone
*
May we text you to communicate with you about your pet(s)?
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Yes
No
Primary E-mail Address (For forms and medical information)
*
Home, Work, or Other # where you may be reached
*
Type? Hours?
*
Place of Employment
*
Occupation
*
How did you find us?
*
Google Search
Location
Local Social Media (ex. Nextdoor, FB group)
Event (Which One?)
Referred By Someone
Event (Which One?)
Name of person who referred you? (We give $ credit to clients for referrals!)
Additional Information
Briefly describe which pet you have with you and the reason for your visit today (wellness, establish relationship, sick visit, etc.).
*
In an effort to make everyone as safe and comfortable as possible, does anyone in the home have SEVERE allergies or PHOBIAS that we should be aware of prior to your visit (peanuts, cats, birds, etc.)?
*
Yes
No
If yes, please explain
Authorizations
Emergency Contact - In the event that you become incapacitated or cannot be reached and an emergency occurs, whom may we contact? This should be someone that you permit to make medical decisions regarding you or your pet(s).
*
First
Last
Relationship
*
Phone
*
Other Phone (if applicable)
Consent
*
I authorize the veterinarian(s) at Middle Creek Veterinary Hospital to handle, examine, prescribe for, or medically treat and/or care for my pet(s).
Consent
*
I understand that the hospital can be scary for many animals. When animals are scared, they sometimes bite or scratch. Because of this and other liabilities, I will not be allowed to restrain my own pet during medical care.
Consent
*
I assume responsibility for any and all charges incurred during and surrounding the care of my animal(s).
Consent
*
I understand that any outstanding balance must be paid at the time of the appointment or release of the animal from the hospital.
Consent
*
I agree to pay a deposit prior to surgery or hospitalization if necessary.
Consent
*
Middle Creek Veterinary Hospital may take photos or videos of my animal(s) during their visit. These photos or videos may be used for education or marketing purposes. We respect your privacy and will NEVER share your personal information on social media. This includes names, private medical information, or faces of humans (especially children).
Name
*
First
Last
Date
*
Date Format: MM slash DD slash YYYY
New Clients
About Us
Our Team
Location & Hours
What To Expect
Take A Tour
Services
Wellness Exams
New Pet Care Consults
Spay & Neuter Services
Routine Vaccinations
Dental Care and Procedures
Emergency Visits
Surgical Services
Forms
Pet Health & Care Guides
How-To Videos
Pet Insurance
Pet Food Recalls
Pet Health Library
Product Recalls
News
Contact Us