Eagle Creek Animal Clinic - New Client

At Eagle Creek Animal Clinic, we love meeting new clients and their pets!

Client Information

Appointment Date(Required)

Appointment Time(Required)

First(Required)

First Name

Last(Required)

Last Name

Address(Required)

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

Spouse/Co-Owner First Name

First Name

Spouse/Co-Owner Last Name

Last Name

Contact Information

Primary Contact First Name(Required)

First Name

Primary Contact Last Name(Required)

Last Name

Primary Phone Number(Required)

Please enter a valid phone number.

Cell

Home

Work

Primary Email

example@example.com

Secondary Contact First Name

First Name

Secondary Contact Last Name

Last Name

Secondary Phone Number

Please enter a valid phone number.

Cell

Home

Work

Secondary Email

example@example.com

How did you hear about us?

Consent

Photo Consent: Do we have permission to take pictures of your pet and post them to our website and/or Facebook page?(Required)

Yes

Medical Records Release Consent: Do you consent to having your medical records released to other pet professionals such as groomers, boarders, trainers and veterinarian offices?(Required)

Yes

Treatment Consent: I hereby authorize the veterinarian to examine, prescribe for or treat my pets to the best of their abilities. I assume responsibility for all charges incurred in the care of my pets. (Please initial)(Required)

Financial Policies

Full payment is due at the time of service. We accept Visa, Mastercard, Discover, American Express, Care Credit, Cash, and Check. The returned check fee is $25.

If you have payment concerns, please discuss with a staff member BEFORE your pet is examined. We can provide you with a written treatment plan including pricing prior to services being rendered.

Missed Appointment Policy: If you miss an appointment without notifying the clinic at least 4 hours before the scheduled time you may be charged a $42 missed appointment fee.

Your signature here indicates your agreement with the above policies and consent:(Required)

Date(Required)

Date

Please select patient species(Required)

Canine

Feline

Patient Information

Feline's Name(Required)

Dog's Name(Required)

Breed(Required)

Colors/Markings(Required)

Date-of-Birth or Approximate Age(Required)

Previous Veterinary Clinic

Microchip Number

How long have you had your dog?(Required)

Current Dog Food(Required)

How long have you had your cat?(Required)

Current Cat Food(Required)

What gender is your dog?(Required)

Male

Female

Is your dog Neutered/Spayed?(Required)

Yes

Unsure

What gender is your cat?(Required)

Male

Female

Is your cat Neutered/Spayed?(Required)

Yes

Unsure

Please select which applies(Required)

I brought my pet's medical records today.

My pet does not have any medical records.

Please call to get my pet's medical records.

Is your dog allowed to have peanut butter and treats while in the clinic?(Required)

Yes

Is your cat allowed to have peanut butter and treats while in the clinic?(Required)

Yes

Please list all other pets in the household:

Make Appointment – Facebook

Eagle Creek Animal Clinic - New Client

Client Information

Contact Information

Consent

Financial Policies

Patient Information