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

If another client, please specify who referred you

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*

Medical History (vaccinations, current medical conditions, diet):*

Pet 2 (optional)

Pet 2 Name

Sex

Species

Breed

Color

Pet Age

Medical History (vaccinations, current medical conditions, diet):

Pet 3 (optional)

Pet 3 Name

Sex

Species

Breed

Color

Pet Age

Medical History (vaccinations, current medical conditions, diet):

Our Fee Policy*

I understand that all fees are due at time of service. 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 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 Animal Center West Omaha 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

Email

This field is for validation purposes and should be left unchanged.

New Client Form