Owner's Name(Required)

First Last

Phone(Required)

Phone Type(Required)

Cell

Landline

Spouse/Co-Owner's Name

First Last

Phone

Phone Type

Cell

Landline

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email(Required)

Alternate Email

Emergency Contact Name(Required)

First Last

Emergency Contact Phone(Required)

Pet's Name(Required)

Species(Required)

Breed(Required)

Color(Required)

Age/Date of Birth(Required)

Sex(Required)

Male

Neutered Male

Female

Spayed Female

Is your pet microchipped?(Required)

Yes

Previous Veterinary Hospital

Previous Veterinary Hospital Phone

How did you hear about our hospital? If by personal recommendation, please tell us who so we can thank them!(Required)

Preferred way to be contacted by our staff about your pet's care?(Required)

Text Message

Phone Call

Appointment Policy

A deposit of $35.00 is required for all appointments that are scheduled with the doctor. Technician appointments do not require a deposit at this time. This deposit is needed within 24 hours of scheduling your appointment. If it is not collected within 24 hours, the appointment will be cancelled and the appointment time will be made available to other patients. The monies collected will be applied towards the cost of care and the balance due at the end of your appointment.

We understand that schedules change and conflicts can arise. We ask that 24-hour notice be given if needing to cancel or reschedule. At that time, we are happy to help reschedule your appointment and apply your deposit to future appointments. If you are unable to reschedule at that time and you would like your deposit refunded to you, we are able to do so.

If you are unable to cancel or reschedule your appointment within 24 hours of your upcoming appointment time, your deposit is non-refundable and a new deposit will be required for future scheduling.

Financial Policy

All services must be paid at the time of service. For your convenience, we accept Cash, Check, Visa, Mastercard, Discover, American Express, and CareCredit. All returned checks will result in a $25 returned check fee. We will be happy to provide a treatment plan (estimate of services) at any time upon request.

I authorize the treatment of my pet by the team at Northfield Veterinary Hospital, and I understand that I am financially responsible for the payment of all services provided.(Required)

Signature

Date(Required)

Comments

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New Client Form

New Client Form

Appointment Policy

Financial Policy

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Contact

Hours

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