New Client Form

New Client Form 2018-05-01T10:40:51+00:00

Client Information

Your name *

Spouse/Other *

Street address *

City *

State *

Zip *

What is the best number to reach you?

Do you have an emergency contact? *
This is someone that we have your permission to reach if we cannot get you.

What is the emergency contact's best phone number? *

What is the email address that you are most likely to check? *
We do not sell our email list and contact clients with information regarding pet care and appointments.

If you would like to receive medical updates about your pet by text, please indicate the phone number here.
You will receive an email allowing you to choose how you want to be contacted soon.

How did you choose us? *
Check all that apply.

If you were referred by someone, please tell us whom to thank.

Pet's Name *

Cat or Dog? *

Age
If you are not sure, you can guess.

Gender *

Important Pet Medical Information
Is there any pertinent previous medical history about your pet that we need to know, like drug reactions or allergies?

What breed is your pet? *
If your pet is a mix, tell us the predominant breed or type "mixed"

What color is your pet?

What is the reason for your visit today? *

Do you have other dogs or cats in your household?
If yes, please list them below.

Treatment Authorization and Payment Policy *

I assume responsibility for all charges incurred at Applebrook Animal Hospital. I know that all charges must be paid at the time of service and a deposit may be required before extensive treatment. In the event this account is placed for collection, I agree to pay all costs of collection, including but not limited to attorney fees and court costs. I understand the policies and consent for my pet's treatment.