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New Client Form

Note: New Clients are encouraged to complete this form before their first appointment with our veterinarian. This form should only be completed by new clients who have already scheduled an appointment with us.

Client Information

Please fill out all Required fields for proper submission

Primary Owner Full Name

Primary Phone Number

Primary Owner Email

Secondary Contact Full Name

Secondary Phone Number

Secondary Owner Email

Appointmet Date

Street Address

Street Address Line 2

City

Postal / Zip code

Patient Information

Please give any of your pets prior records to the receptionist

Pets Name

Male or Female?

Pet Color

Previous Veterinarian

Pet Age/Date of Birth

Pet Breed

Reason for your visit with us today

I hereby authorize the veterinarian to examine, prescribe for, and treat the above pet. I certify that I am 18 years of age or older and that I am legally financially responsible for the treatment received at NorthPointe Animal Hospital. I will assume responsibility for all charges incurred for the care of this pet. I understand that FULL PAYMENT IS DUE AT THE TIME THE SERVICES ARE RENDERED and that a DEPOSIT MAY BE REQUIRED FOR ANY HOSPITALIZED OR BOARDED PET.

I agree to the terms & conditions

Your Signature