New Client Information Form

Thank you for considering our hospital as your pet’s provider of veterinary services. We are dedicated to maintaining the health of your pet and look forward to many future years together.

Please complete this form as fully as possible prior to your first appointment which will help expedite the registration process and give us valuable insight in providing optimal care for your pet(s). The required sections have a blue * asterisk.

Owner's Information

Name*

First Last

Address*

Street Address Apt/P.O. # City State Zip Code

Home Telephone Number*

Mobile Number*

Email*

Enter Email Confirm Email

Pet Information

Pet's Name*

Species*

Dog
Cat

Sex*

Male
Female

Is your pet Spayed/Neutered?*

Yes
No

Breed (if known)

Date of Birth or Age (if known)

Color

Does your pet have a microchip?*

Yes
No

If so what is the microchip number:

Was your pet rescued from a shelter or rescue group?*

Yes
No

Was your pet adopted from North Shore Animal League America?*

Yes
No

If so what is the adoption number:

Other Related Information

How did you find out about our practice?

What is the full name of the referee?

Please read and agree:

Thank you for choosing North Shore Animal League Pet Health Center as your veterinary health care provider. We are dedicated to providing the highest quality health care to all of our patients. In order to assist in an increasing number of patients, and to keep our services at affordable costs while providing the highest quality of care, we cannot extend credit. Please understand that payment is due at the time of services rendered. We may also require a deposit for major procedures. The following payment options are accepted:

*Cash or personal check with valid state license/ID. Checks are electronically processed the same day. WE DO NOT ACCEPT POST DATED CHECKS
*Bank credit or debit card. We accept payment from all major credit cards

Policy Agreement*

By submitting this form, I have read, understand, and agree to the above financial policy.

New Clients

Owner's Information

Pet Information

Other Related Information

Please read and agree: