New Client Form

"*" indicates required fields

Thank you for considering Bethany Family Pet Clinic as your medical veterinary care provider of choice! As a client of our animal hospital, you can expect our full attention to your pet’s needs.

This form is required for all new clients, and will speed up your appointment if filled ahead of time. If you have already scheduled an appointment, we will see you at your scheduled time. If you have not yet scheduled, a staff member will be reaching out to you after you fill out the form, or you can request an appointment.

Client Information

Owner's First Name*

Owner's Last Name*

Address*

Street Address

Address Line 2

City

State

ZIP Code

Primary Phone*

Email*

Co-Owner's First Name

Co-Owner's Last Name

Co-Owner's Phone

Pet Information

Please use this area to give us any other relevant information about yourself or your family.

Pet's Name*

Species*

Cat

Dog

Breed*

If Known

Color*

Age*

If Known

Sex*

Female

Female Spayed

Male

Male Neutered

Would you like to add a second pet?*

Yes

Second Pet Information

Pet's Name*

Species*

Cat

Dog

Breed*

If Known

Color*

Age*

If Known

Sex*

Female

Female Spayed

Male

Male Neutered

Would you like to add a third pet?*

Yes

Third Pet Information

Pet's Name*

Species*

Dog

Cat

Breed*

If Known

Color*

Age*

If Known

Sex*

Female

Female Spayed

Male

Male Neutered

Additional Information

What is the reason for your visit?*

How did you hear about us?

Referred by a current client

Google

Facebook

Live in the area

Other

Please list how you herd about us*

If you selected "Referred by a current client", please let us know their full name.*

Bethany Family Pet Clinic Credit Policy

In the interest of quality client service and good business practices, we would like to
communicate the following. If you have any questions, please connect with a
member of our team at 503-614-9061.

Our credit policy requires that all changes resulting from care given to your pet by Bethany Family Pet Clinic are due and payable in full at the time your pet is discharged.

Due to an increase in no-call no-shows, we are now requiring a $79.50 deposit at the time of scheduling. This will be applied to your final bill when services are rendered. This deposit is non-refundable if the appointment is cancelled within 24 hours of the scheduled appointment. We appreciate your cooperation as we strive to see every patient in a timely manner.

At your request, our doctors and staff are happy to provide you with an estimate of
cost for your pet’s treatment. Daily updates on treatment costs for your pet will be
provided at your request

In the event that a balance is left unpaid, a monthly interest fee will accrue on the
unpaid balance at the rate of 1.5 % per month. Interest will start to accrue the day
your pet is discharged from the clinic. Accounts that become delinquent past 90
days may be referred for collections and may be assessed a collection fee.

Returned/NSF checks will be subject to a $35.00 fee, as specified by state law.

In the event that, for whatever reason, you are unable to pay the balance due at the
time of service, other payment arrangements must be made and approved with us
before the work is performed. It is your responsibility to let us know ahead of time if
you are unable to pay at the time of service.

I understand and accept that I am financially responsible for payment for all services received.

Signature

I certify that all information I have provided is correct to the best of my knowledge,
and that I am the legal owner, guardian or authorized representative for the pets
listed on this form. I have read, and I accept the credit policy outlined above. I agree
that in the event additional costs and/or fees are incurred in connection with the
collection of my account, I will pay all such costs and fees, including but not limited
to collection costs, attorney fees and all court costs.

Signature*

Date*

MM slash DD slash YYYY

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Name

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

Client Information

Pet Information

Second Pet Information

Third Pet Information

Additional Information

Bethany Family Pet Clinic Credit Policy

Signature

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503-614-9061

503-614-9061

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