New Client Form for Vet Visits | Prescott Animal Hospital

Full Name(Required)

First

Last

Secondary Owner's Name

First

Last

Mailing Address(Required)

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country

Primary Phone(Required)

Secondary Phone

Email(Required)

We use email addresses to send health care reminders and also 24/7 access to your Pet Portal. With a PetDesk you have access to your pet’s vaccination history, medication information and much more- anywhere, anytime. Ask us how to sign up!–We will keep your email PRIVATE.

Emergency Name(Required)

Emergency Contact Phone number(Required)

How did you hear of our hospital?

Other

Whom we may thank for referring you?

#1 Patient Information

Previous Veterinarian(Required)

Phone(Required)

Permission is hereby given to have records for the animals listed below transferred.

Name

Breed

Color

Age/DOB

Sex

Spayed / Neutered

Do you need to add another pet?

Yes

No

#2 Patient Information

Previous Veterinarian(Required)

Phone(Required)

Permission is hereby given to have records for the animals listed below transferred.

Name

Breed

Color

Age/DOB

Sex

Spayed / Neutered

Professional Services
Professional services are due at the time services are rendered. We will gladly prepare a written estimate for any service upon your request. We accept the following methods of payment: cash, check, Master Card, Visa, American Express, Discover, Care Credit. For your convenience, we are able to keep your credit card number on file by completing our Auto Pay Form. Then we can process payments for regular visits or when you are out of town and others seek medical care for your pet. Please ask any team member for the Auto Pay Form. A finance charge computed at a periodic rate of 1.5% per month (annual percentage rate of 18%) will be applied to all accounts unpaid after thirty (30) days. The minimum finance charge will be $1.00. Applicable fees will apply on any returned check as well as any account with an unpaid balance requiring services of a collection agency. We do not have a 24-hour attendant. There will be periods of time when those animals hospitalized overnight will not be under direct supervision. Please feel free to inquire about our hospitalization policies. I agree to pay for all professional services and medications rendered in the care of any animal I bring to Prescott Animal Hospital. Furthermore, I understand that in order to prevent the spread of infectious diseases and parasites, hospitalized and boarded animals must have documentation of current proof of vaccines and be free of parasites. I authorize Prescott Animal Hospital to provide vaccines and parasite control as needed for my pet.

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