New Client Information

Owner: *

First

Last

Co-Owner: *

First

Last

Address: *

Address Line 1

Address Line 2

City

State

Zip Code

Main Phone: *

Cell Phone:

Would you like to receive text messages?

Yes
No

Additional authorized contact name and number: *

You authorize us to speak to this person about your pet’s care in the event we cannot reach you.

Email: *

Do you qualify for the following discounts?

Senior Citizen
Active-Duty Military
First Responder/LEO

New Patient Information

Pet's Name: *

Species: *

Dog
Cat

Breed: *

Sex: *

Male
Female
Male Neutered
Female Spayed

Color: *

Birthday/Age: *

Previous Health Issues: *

Do you have a second pet? *

Yes
No

Pet's Name *

Breed: *

Dog
Cat

Species: *

Sex: *

Male
Female
Male Neutered
Female Spayed

Previous Health Issues: *

We love social media! We would like your consent to share your pets’ image(s) on our social media and website. *

Yes, please make my pet a star!
No, thank you; my pet is shy

Your full name and personal information will never be used.

Cancellations: If you must cancel an appointment, we ask for 24-hour notice. If cancelling a surgical appointment, we ask for 48-hour notice. A late cancellation or frequent cancellations may result in a fee being applied to your account. Current vaccinations are required by Chester Animal Clinic before we may admit any animal for any reason. We are a flea-free hospital so if your pet is found to have fleas, we will administer flea control at your cost. These measures are taken to protect the well-being of all animals within our hospital.

Treatment Consent: I hereby authorize the veterinarian to examine, prescribe for or treat the above-described pet(s). I assume responsibility for all charges incurred in the care of this animal. I understand that payment is always due in full at the time of services rendered.

For your convenience we accept Visa, Mastercard, American Express, Discover, Care Credit, Scratch Pay, Trupanion Express and Cash. Please stop at the reception desk to review and pay for services.

I confirm *

I confirm that the above information is correct, that I am at least 18 years of age and that I am the owner or authorized agent of the patient(s) listed above.

Signature: *

Clear Signature

Date: *

New Client Form

New Client Information

New Patient Information