New Client Form

Form - New Client

First and Last Name (required)

Your Address (required)

City (required)

State (required)

Zip (required)

Daytime Phone (required)
CellHomeWork

E-Mail Address (required)

Pet's Name (required)

Age: Years, Months (If known, or best guess)

Type of Pet(required)
CanineFelineAvianExoticOther

Breed:

Sex (required)
 Male Female

Neutered/Spayed (required)
 Yes No

Are your pet's vaccines current?
 Yes No

Please mail, fax, or bring your medical records at the time of your visit

Name of former veterinary practice:

May we request a transfer of records?
 Yes No

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 LePar Animal Hospital 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 LePar Animal Hospital'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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