New Client Registration Form

Welcome To Coastal Plains Animal Clinic !!

Thank you for giving us the opportunity to care for your pet. Please help us meet your needs better by taking a moment to share some important information we will need as we support your pet’s needs today and in the future. PLEASE PRINT IN ALL SPACES.

Client's Name*
Spouse/Other*
Address
Street Address City State / Province / Region ZIP / Postal Code
Drivers License#
Soc. Sec. #
Spouse Drivers License#
Spouse Soc. Sec. #
Home Phone*
Cell
E-mail
Employer
Work Phone
Spouse/Other Employer
Work Phone
Can we call to talk to you about your pet?
At what time
At what phone number
Who would we ask for?
Alternate Emergency Number
We will gladly prepare a written estimate if you desire (please ask our doctor OR receptionist). This will be important to you since ALL PROFESSIONAL FEES ARE DUE AT THE TIME SERVICES ARE RENDERED. In cases of extensive medical or surgical procedures, when full payment may be difficult at discharge, we take Master Card, Visa, Discover, American Express, and Care Credit.

To prevent the spread of infectious diseases, all hospitalized and boarded patients must be current on all vaccines and free from internal and external parasites. The signature below authorizes this level of preventive care and the appropriate charges will be assessed in the discharge invoice.
Signature of Responsible Agent for Pet(s)
Date
MM slash DD slash YYYY
How/Why Did You Select Us?
Are You Interested in Behavior Management Assistance?
If your pet(s) travel (or have traveled) out of the area, where?
Cat Dog Sex DOB Other Pet’s Name Description

New Client Registration Form

Welcome To Coastal Plains Animal Clinic !!

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Cat	Dog	Sex	DOB	Other	Pet’s Name	Description