New Client Registration

First Name (required)

Last Name (required)

Address (required)

Phone Type

Day Time Phone

Phone Type

Evening TimePhone

Your Email (required)

Pet's Name

Pet's Age: Years, Months

Pet Type

Breed

Pet's Sex
MaleFemale

Neutered/Spayed
YesNo

Are your pets vaccines current?
YesNo

Do you have pets medical records?
YesNo

Medical records at another veterinary Practice?
YesNo

Name of Former Veterinary Practice

May we request a transfer of records?
YesNo

Would you like us to call you for your appointment?
YesNo

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 Douglas Blvd Veterinary Clinic 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 Douglas Blvd Veterinary Clinic'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 AgreeI Disagree

Please leave this field empty.