Client and Contact

First and Last Name

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Home Phone*

Cell Phone*

Email*

How did you become aware of this clinic?

Choose one*

If other, please specify

Emergency Contact Person*

Home Phone*

Cell Phone*

Name of Previous Veterinarian

Phone of Previous Veterinarian

Pet Information

Pet 1

Pet 1 Name*

Sex*

Species*

Breed*

Color*

Pet Age*

Pet 2 (optional)

Pet 2 Name

Sex

Species

Breed

Color

Pet Age

Pet 3 (optional)

Pet 3 Name

Sex

Species

Breed

Color

Pet Age

Our Fee Policy*

I understand that all fees are due at time of service. We accept Cash, Checks, Debit, Visa, MasterCard, American Express, Discover, CareCredit, Apple Pay, Trupanion, and Trupanion Express. If you are in need of alternative payment arrangements please discuss that prior to completion of services.*

Yes, I understand the fee policy.

Consent*

I hereby authorize the veterinarian to examine, prescribe for or treat the above described pet(s). I understand that all animals must be current on vaccinations and testing for boarding, grooming, daycare and hospital procedures. I assume all responsibility for all charges incurred in the care of my animals. I also understand that these charges will be paid for at the time of release and that a deposit may be required for surgical treatments or hospitalization.  

Photo Release: I agree that Belmont Veterinary Center may use such photographs of me and/or my pet(s) with or without my name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising, web content, or social media sites.  I have read the above statement and by submitting this form, I understand and agree to the conditions above.*

Accept