Audubon Veterinary Associates

New Client Check In

If you would like to make an appointment, you can assist us to expedite your check in by submitting this form.  Kindly complete this form 24 hours prior to your appointment.

Thank you for your cooporation in letting us assist you.

Form - New Client

CLIENT INFORMATION
Name (required)
First Name (required)
Last Name (required)
Spouse's Name
First Name
Last Name
Address (required)
Street Address (required)
City (required)
State/Province (required)
Zip/Postal Code (required)
,
Home Phone (required)
Phone TypePhone Number (required)
Cell Phone
Phone TypePhone Number
Occupation

Employer

Work Phone
Phone TypePhone Number
Spouse's Occupation

Spouse's Employer

Spouse's Work Phone
Phone TypePhone Number
E-Mail Address :
Drivers License # (necessary if paying by check)

PET INFORMATION
Pet's Name (required)

Type of Pet (required) :
Age: Years, Months or Birthdate

Sex: (required)
Male
Female

Neutered/Spayed
Neutered
Spayed

Breed:

Color

Are your pets vaccines current?
Do you have pets medical records?
Medical records at another veterinary Practice?
Yes
No

Name of Former Veterinary Practice

Reasons or conditions that prompted your visit?

Special requests or conditions?

Please list any additional pets here

Please Read
I understand, by indicating I agree and submitting this registration, that I am responsible for any charges incurred by my pet while in the care of the doctors at Audubon Veterinary Associates and that charges are due and payable at the time of service, unless other arrangements are made in advance. Any balance that is carried over a period of 30 days will accrue a monthly finance charge of 1.5% or 18% per annum. Any balance that I leave unpaid will be forwarded to Audubon Veterinary Associates's collection agency, and will incur a 25% collection fee for which I am liable, in addition to monthly finance charges.
I have read this statement and -
I Agree
I Disagree


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