Client Information

First name

Last name

Phone

Co-Owner Name

Alternate Phone Number

Address

City

State

Zip Code

Email

How did you hear about us?

Pet Information

Pet's Name

Species

Sex

Breed

Color

Birthday

Month

Day

Year

Has your pet ever had a reaction to vaccines or medication?

Yes

No

If yes, please explain:

Do you authorize Silver Creek Animal Hospital to obtain your pet's records?

Yes

No

Name of clinic to contact for records:

Do you give us permission to take photos of your pet and use them on marketing materials (social media, pamphlets, in hospital)?

Yes

No

Terms of Service

Payment in full is required at the time of services rendered. We accept all major credit cards or cash. We do not accept checks.

I have read and agree to the payment policy.

We value the trust you place in our team to care for your pets. We will treat you with kindness and respect and ask that you do the same for our team. We have a zero tolerance policy for bullying/cyberbullying, harassment, defamation, aggressive tones or threats of any kind. We reserve the right to decline services for client behavior at any time. Should it be necessary, we will send your records to you so that you can continue your pet's care elsewhere.

I have read and understand the behavior policy.

All of the information provided is true to the best of my knowledge. I have read, understand and agree to the terms of service.

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Signature

Today's Date

Month

Day

Year

info@silvercreekpets.com

New Patient Form

Client Information

Pet Information

Terms of Service