New Client Form

Owner's Name:
Spouse’s Name:
Address:
City/State:
Zip:

Phone Numbers
Home:
Cell #1:
Cell #2:

Personal Information
Employer Name:
Phone:


Driver’s License / State:
D.O.B:
Email Address:

How did you hear about us?
(Please specify if friend / neighbor)

 
Pet Information
First Pet
Patient:
Dog Cat
Breed:
Male Female
Color:
Spayed Neutered Intact
D.O.B.:
 
Second Pet
Patient:
Dog Cat
Breed:
Male Female
Color:
Spayed Neutered Intact
D.O.B.:
 
Third Pet
Patient:
Dog Cat
Breed:
Male Female
Color:
Spayed Neutered Intact
D.O.B.:
 


Can we obtain previous records? Yes No
Clinic Name:
Clinic Phone:

I hereby authorize the staff of Premier Pet Resort & Day Spa to render any treatment, which is deemed necessary to my pet’s health while in the custody of this hospital. I understand that in the event of any unusual or emergency circumstance, the staff will make every attempt to contact me or my designated representative before, if time permits, proceeding with treatment. I understand I will be financially responsible for all emergency procedures including the estimate of charges provided to me in person or over the telephone. I understand that professional fees are to be paid at the time services are rendered and a deposit may be required on all pets admitted into the resort.