New Client Form

New Client Form

New Client Form

New Client Form

New Client Form

Welcome to Peavine Animal Hospital!

We are accepting new clients! We need you to provide medical records from your previous veterinarian and complete our new client form. We suggest you request those records to be emailed to you, so you have your own copy, then print a copy for us. Our new client form is on our website for you to complete and submit or print. We will make your appointment once we have those two pieces of information from you.

There are two ways for you to share your information with us:

1. You may complete the digital version of our New Client Form below and then click SUBMIT.
Your information will be forwarded electronically to our clinic.

OR

2. You may use the PDF version by clicking the DOWNLOAD PDF to Print button and then completing the printed form by hand. Please bring the completed PDF form with you for your pet’s first appointment.

Download PDF

Name*

Email*

Phone*

Alternate Phone

Address*

Address Line 1
City
State
Zip code

How would you prefer to receive reminders? *

Who shall we thank for your referral?

Add a spouse or approved secondary owner? *

If yes, please fill up the fields below:

Name

Email

Phone

Address

Address Line 1
City
State
Zip code

I authorize treatment and/or service for any animal I bring to Peavine Animal Hospital. I agree to pay for all charges at the time services are rendered for my pet(s). I certify that I am the primary owner of the pet(s) listed in this form and am at least 18 years of age, or older. I authorize the secondary owner has the authorization to sign for any treatment(s) and settle any balance for my pet(s). I understand new clients require a deposit on the initial appointment and all surgeries require a deposit. I will inform Peavine Animal Hospital of any abnormal symptoms my pet(s) may be having at the time of check-in at each appointment. I understand that the staff of Peavine Animal Hospital will put my pets’ health first and foremost and that in the incident a medical-related reaction or incident occurs, I do not hold Peavine Animal Hospital responsible. I understand there are no-show and cancellation fees in the price of the examination if there is less than 48 hours notice of the cancellation. I also understand that I may be required to leave deposits for future services. I have read and understood all the above provisions of the Client Agreement with Peavine Animal Hospital. *

Would you like to Request an Appointment?

What is the purpose of this appointment?

Patient Information

Name*

Breed*

Species *

If Other, please specify.

Age/D.O.B.*

Color/Markings*

Sex *

Has your pet been seen previously at any other veterinary clinic/hospital? *

If so, what is the name of the previous clinic/hospital? *

Any known reactions to medications or vaccinations? *

If yes, Please explain. *

Add another pet? *

If yes, please fill up the fields below:

Name

Breed

Species

If Other, please specify.

Age/D.O.B.

Color/Markings

Sex

Any known reactions to medications or vaccinations?

If yes, Please explain.

PAYMENT TERMS & AGREEMENT: Payment in full is required at the time services are rendered. You may pay with one of the following: Cash, check (current clients), or credit cards (VISA®, MasterCard®, and American Express®. Peavine Animal Hospital does not provide in-house billing. If you need more time to pay a large bill, you may apply for a payment plan through CareCredit®, ScratchPay®, or VetBilling®. Your credit history will determine whether you qualify for a payment plan. Ask one of our staff members for assistance if you wish to apply for a payment plan. 50% of the estimate for the cost of treatment plan is required as a deposit at the time of admission for all surgery, hospitalization, dentistry, and emergencies unless the client has a payment plan in place. *

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