mcclurevetclinic.com - New Client Form

Owner*

First NameLast Name

Address *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Primary Phone Number *

Please enter a valid phone number.

E-mail Address *

example@example.com

Co-Owner

First NameLast Name

Alternate Phone Number

Please enter a valid phone number.

Employer Name

Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Preferred Method of Payment

CashCredit/Debit CardLocal Check

Driver’s License Number & State

Date of Birth

Date

Referred By

We consider our pet(s) as:*

Part of the familyJust as Pets

Please list your previous veterinary clinic:

Can we contact your previous veterinary clinic for your pets’ records?

YesNo

Please List all your pets’ names, species, breed, age, sex, and if they are spayed/neutered:*

Do you grant McClure Veterinary Clinic and its representatives permission to take photographs of you, your family, and/or your pet(s) and publish electronically on our social media & website? *

YesNo

We will gladly prepare a written estimate upon request for any treatment. Please ask a team member. All professional fees are due at the time of services rendered. A deposit prior to treatment may be required depending on the amount of the estimate. To keep everyone safe and abide by state laws all pets are require to be current on Rabies vaccinations.*

I Understand

As the responsible owner or owner’s agent for the pet(s) being presented to this facility, and agreeing to abide in full by the above stated hospital policies, I hereby consent and authorize McClure Veterinary Clinic to receive, prescribe for, treat, or operate upon my pet(s). As a client of McClure Veterinary Clinic, I understand that the practice’s basic philosophy is to tell me what my pet needs to remain healthy and protected from disease. I also understand that I have the right to waive my pet’s rights to the level of care being offered by the veterinarian. I also understand that I assume the responsibility and liability that I place my pet into such action. I understand that McClure Veterinary Clinic is not staffed 24 hours daily. If my pet is hospitalized for overnight treatment with McClure Veterinary Clinic, and if intensive care or observation is warranted or advisable, the veterinarian will either perform these services, or in the event that she is unable to do so, your pet will be referred for the night to an emergency clinic that is fully staffed during that time. I authorize the doctor to provide vaccines and parasite control as needed for my hospitalized pet(s) at my expense (if required) in accordance with the above stated hospital policy. Should an emergency situation arise, I authorize the veterinarian to do whatever is necessary, including tranquilization as required. I understand that I assume complete financial responsibility for all services rendered, and that payment is due in full at the time of completion of services rendered, or upon release of the patient from our facility.

I Agree

Signature*