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New Client Form

Thank you for giving us the opportunity to care for your pet(s). So that we may become better acquainted, please complete the following:

Client Information

Spouse's Name
Pet Information
Click the plus (+) icon to add more pets.
Spayed/Neutered (Yes/No)
Last Known vaccination date
Last Known Heartworm Test (dogs)
Last Know FeLv/FIV test (cats)
Are they:
Do they:

Financial Policy

We are so happy to help you with the needs of you furbabies, but ask that you understand that payment is due for products and services at the time services are rendered.

We apologize, but we do not accept checks, however we do accept cash, credit/debit cards, all major credit cards and Care Credit (Care Credit charges must exceed a minimum to $200 to be accepted).

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Photo Release

Countryside Animal Hospital has my permission to use photographs of my pet on their social media and website platforms. I understand that the photographs may be used in print publications, online publications, and presentations. I further understand that no royalty fee or other compensation shall become payable to me for such use.
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This field is for validation purposes and should be left unchanged.