Personalized, Compassionate Care

               For Your Family Pet

New Client Check In Form

Please fill out this form, print it and bring it with you at the time of your appointment. Thank you.

Form - New Client

Name & Email (required)
First Name (required)
Last Name (required)
Address (required)
Street Address (required)
City (required)
State/Province (required)
Zip/Postal Code (required)
,
Daytime Phone (required)
Phone TypePhone Number (required)
Evening Phone (required)
Phone TypePhone Number (required)
E-Mail Address :
Pet's Name (required)

Age: Years, Months

Type of Pet (required) :
Breed:

Sex: (required)
Male
Female

Neutered/Spayed
Neutered
Spayed

Are your pets vaccines current?
Do you have pets medical records?
Medical records at another veterinary Practice?
Yes
No

Name of Former Veterinary Practice

May we request a transfer of records?
Yes
No

Would you like us to call you for your appointment
Reasons or conditions that prompted your visit?

Special requests or conditions?

Please list any additional pets here

Please Read
I give permission to Erie Animal Hospital to publish my pet(s) pictures on any correspondence/website/print material.
I have read this statement and
I give permission
I do not give permisssion

Please Read
I understand, by indicating I agree and submitting this registration, that I am responsible for any charges incurred by my pet while in the care of the doctors at Erie Animal Hopsital and that charges are due and payable at the time of service, unless other arrangements are made in advance. Any balance that is carried over a period of 30 days will accrue a monthly finance charge of 1.5% or 18% per annum. Any balance that I leave unpaid will be forwarded to Erie Animal Hospital collection agency, and will incur a 25% collection fee for which I am liable, in addition to monthly finance charges. All returned checks will be charged a $20 fee. You will be required to provide a valid driver's license for all checks written.
I have read this statement and -
I Agree
I Disagree


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