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.

Spears Animal Hospital New Client Form

Pet Owner Information

"*" indicates required fields

Owner:*(Required)

First* Middle Last*

Drivers License #:*(Required)

DOB:

State Issued:*(Required)

Address:*(Required)

Street* City* State* Zip Code*

Cell:*(Required)

Home Phone:

Work Phone:

Email Address:*(Required)

Spouse/Partner Information

Spouse:*(Required)

First* Middle Last*

Email Address:*(Required)

Cell:*(Required)

Home Phone:

Work Phone:

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Employment:

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Employer

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Your Title

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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:*(Required)

First* Last*

Phone:*(Required)

Email Address:

Address:*(Required)

Street* City* State* Zip Code*

Patient Information

Pet's Name:*(Required)

Breed:*(Required)

Color:*(Required)

Sex:*(Required)

DOB:*(Required)

Species*(Required)

Indoor/Outdoor Pet?*(Required)

Allergic Reactions*(Required)

Spayed/Neutered?(Required)

Is Your Pet Microchipped?(Required)

Microchip Number:

Previous Animal Hospital(s)(Required)

Hospital Name:*

Hospital Phone:*

If your pet has not been to a vet yet (such as a new puppy or kitten), please put 'not applicable' in the above fields.

Visit Type*(Required)

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

Would you like home delivery for food and medication?

Would you like to receive vaccine reminders?

Do you have your pet's medical records?

Upload Medical Records

Max. file size: 15 MB.

If available, please upload your pet's medical records.

How did you hear about us?*(Required)

Friend we can thank

Hospital Sign/Location

Website/Google

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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Name

This field is for validation purposes and should be left unchanged.