New Client Check In If you would like to make an appointment, you can expedite your check in by submitting this form. Thank you for your cooperation in letting us assist you! NAME required First Name Last Name Email Address ADDRESS required Street Address City State/Province Zip/Postal Code DAYTIME PHONE required Phone Type Home Cell Work Phone Number EVENING PHONE required Phone Type Home Cell Work Phone Number PET INFORMATION required Pet’s Name Age (Years, Months) Breed Sex Male Neutered Female Spayed Are your pets vaccines current? Yes No Do you have pets medical records? Yes No Medical records at another veterinary practice? Yes No 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, which I am responsible for any charges incurred by my pet while in the care of the doctors at Veterinary Village, LLC 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 Veterinary Village, LLC'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
