New Client Form | St. Francis Animal Hospital

We’re Here for You and Your Pets

Welcome to the St. Francis Animal Hospital practice! Please fill out this New Client Form before your first appointment so we can get to know you and your furry friends.

New Client Form

Payment Policy Form

"*" indicates required fields

Company

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

Pet Owner Information

Owner:*

First Middle Last

Address:*

Street City State Zip Code

Contact

Cell*

Home

Work

Email Address*

Employment

Employer

Address

Spouse/Co-Owner

Name:

First Last

Cell

Email Address

Patient Information

Pet's Name

Breed

Color

Sex

Age

Spayed/Neutered?

Allergic Reactions

List dates boosters were last given:

Is your pet currently on a special diet or medication?

Is your pet on Heartworm prevention(What Kind)?

Is your pet on Flea prevention(What Kind)?

Is your pet on Tick prevention(What Kind)?

What food does your pet eat?

List all previous problems that we should know about:

How did you hear about us?

checkbox

GOOGLE

YELP!

FACEBOOK

OTHER

I am financially responsible for my pet and agree to pay all fees incurred. I understand that any medical or surgical procedure is attended by some risk, and that it is not possible to guarantee the successful outcome of such procedures.

This agreement is in force from this date forward unless I notify the clinic in writing to the contrary.

Owner Signature*

First Last

WE DO NOT ACCEPT CHECKS

Payment is expected when services are rendered

At St. Francis Animal Hospital, our goal is to provide the highest quality veterinary care while maintaining clear and consistent financial policies. Please review the following payment policy carefully. Payment Terms: ● Payment is due in full at the time of service. ● St. Francis Animal Hospital does not offer in-house payment plans. ● For extended payment options, clients may apply for third-party financing through: ● Scratchpay (www.scratchpay.com) ● CareCredit (www.carecredit.com) Approval and payment arrangements are the responsibility of the client and subject to the terms of the third-party provider. Exam Fees: ● The examination fee includes only the physical examination of the patient. ● Additional services—including but not limited to diagnostic testing, treatments, procedures, and medications—are not included in the exam fee and will incur separate charges. Accepted Forms of Payment ● Cash ● Credit cards (Visa, Mastercard, American Express, Discover) ● CareCredit ● Scratchpay Please note: A service charge will be applied to all credit card payments. Acknowledgment: I acknowledge receipt of the St. Francis Animal Hospital Payment Policy and agree to abide by the terms and conditions stated above.

Owner Signature*

First Last

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