New Client Form | Spears Animal Hospital

Welcome, New Clients!

If you would like to make an appointment, you can assist us to expedite your check-in by submitting this form.

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Pet Owner Information

"*" indicates required fields

Owner:*(Required)

First* Middle* Last*

Drivers License #

DOB

State Issued

Address:*(Required)

Street* City* State* Zip Code*

Telephone:*

Cell*(Required)

Home

Work

Spouse/Partner Information

Spouse:

First Middle Last

Email Address

Spouse/Partner Telephone:

Cell

Home

Work

Employment:

Employer

Your Title

Address

In Case of Emergency

Please provide us with a relative's information in case of an emergency. Relative must be of a different household.

Relative's Name

First Last

Phone

Patient Information

Pet's Name

Breed

Color

Sex

Age

Species

Indoor/Outdoor Pet?

Allergic Reactions

Spayed/Neutered?

Microchip Number

Previous Animal Hospital Name

Previous Animal Hospital's Phone

Are you here for a one-time visit or to become a client of Spears Animal Hospital?(Required)

Would you like home delivery for food and medication?

Would you like to receive vaccine reminders?

How did you hear about us?(Required)

Friend we can thank

Hospital Sign/Location

Website

Professional Referral

Other

If 'other', please specify:

If personal referral, who can we thank?

We accept the following methods of payment with appropriate identification:

Cash, Visa/Mastercard/Discover: No ID required to accept payment

Check: Driver's License and Social Security Number required to accept payment

Fees are due at the time services are rendered. I understand that I am responsible for the payment on all services rendered, including attorney's fees and collection costs in the event of default.

A 1.5% monthly service charge will be added to accounts over 30 days past due, with a minimum service charge of $1.00.

I attest that the information I have provided above is true and complete.

Owner/Authorized Agent Signature:*(Required)

First* Last*

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