New Client Form

Save time during your appointment. Complete your new client form online from any device before your visit. Existing clients, please use AllyDvm to schedule your appointment.

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New Client Form

Thank you for giving Family Pet Clinic, S.C., an opportunity to care for your pets. So that we may be better acquainted and provide the best services for you and your pets, please complete the below form.

Download Form

Date *

Owner Information

Owner Name *

First

Last

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Email *

Best time to contact *

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Primary Phone Number *

Alternate Phone Number

Phone Type *

Alternate Phone Type

Address *

Address Line 1

City

State

Zip Code

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Owner's Occupation

Place of Employment

City/State

Is there a Co-Owner/Spouse for your pet?

Relation to Owner

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Contact Authorization

Checkboxes *

In providing an email address and/or cell phone number, I give Family Pet Clinic permission to contact me via email/text for the following items I have marked, when it is an option. Family Pet Clinic will do their best to provide reminders and updates, however I understand that the best way to make sure my pet is current, is to call Family Pet Clinic.

(Please mark the following with how you would prefer to be notified, when possible. Check all that apply.)

Did you pet previously attend another clinic? If so, which one?

Emergency Contact

In case of an emergency and we cannot contact you, who may we contact? Can this contact be given authority to make decisions regarding your pet’s care? *

Client/Pet Image Release

I hereby give Family Pet Clinic permission to obtain photographs and/or video of my pets which may be used to help maintain things such as social media and the FPC website. They may be included in anyways that allow for client education, marketing and/or the running of Family Pet Clinic. I give permission to use my pets photos/videos along with their first name only. *

I GIVE Family Pet Clinic permission
I DO NOT give Family Pet Clinic permission

How did you learn about Family Pet Clinic? *

(Personal Referral, Facebook, Yelp, Google Search, Drive-By, etc.) If a personal referral, please list their name so we can thank them!

I hereby authorize Family Pet Clinic and its veterinarians to examine, diagnose, prescribe and treat my pets. I understand that full payment is due at the time services are rendered, including those deemed necessary for medical or surgical complications or unforeseen circumstances. It is our policy to provide you with a written estimate of fees for any case, when possible. For extreme circumstances and with prior approval, a payment plan may be worked out requiring a deposit between 50% and 75% down prior to treatment. *

I acknowledge that I have read, understand and agree with the above information.

Signature *

Clear Signature

Date *

Name

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