New Client Form

Date
MM slash DD slash YYYY
Name
First Last
Co-Owner/Spouse Name
First Last
Address
Street Address Address Line 2 City State ZIP Code
Phone
Work Phone
Co-Owner/Spouse’s Phone
Co-Owner/Spouse’s Work Phone
Email
YOUR DRIVERS LICENSE IS REQUIRED AT REGISTRATION FOR IDENTIFICATION AND INFORMATION VERIFICATION. ALL FEES ARE DUE AND PAYABLE AT THE TIME SERVICES ARE RENDERED. WE DO NOT OFFER FINANCING OR IN-HOUSE CREDIT!

We accept the following forms of payment: Cash, Check, Visa, Mastercard, Discover, American Express and Care Credit.
How did you become aware of our clinic?
- Yellow Pages
- Sign
- Newspaper
- Internet
- Clipper Magazine
- Flyer
Personal Recommendation (Whom may we thank?)
Do you have pet insurance? If so, which company do you use?
- Yes
- No
If yes
Occasionally, photos of pets are included on our website and our Facebook page. In order for your pet’s image to be included in either of these areas, DCAC, Inc. must have your written permission on file. Check One:
- YES, DCAC, Inc does have permission to use images of my pet on the website and Facebook page.
- NO, DCAC, Inc does NOT have permission to use images of my pet on the website and Facebook page.
Pet 1
Name
Species
- Dog
- Cat
- Bird
- Other
If other
Breed
Color
Age
Sex
- Male
- Female
Has your pet been spayed or neutered?
- Yes
- No
Special Diet/Medications:
Date of last known vaccinations:
Where were they administered?
What vaccs were administered?
Pet 2
Name
Species
- Dog
- Cat
- Bird
- Other
If other
Breed
Color
Age
Sex
- Male
- Female
Has your pet been spayed or neutered?
- Yes
- No
Any Known Allergies?
Special Diet/Medications:
Date of last known vaccinations:
Where were they administered?
What vaccs were administered?
Please note: Current vaccinations by a licensed veterinarian are required for the admission of your pet to our hospital. Owner administered vaccinations are not acceptable. This includes admission for elective surgery, boarding, grooming and well animal care. Proof of vaccinations is required prior to admission and is the responsibility of the client.

I agree to allow the doctors and staff of Desoto County Animal Clinic to treat my pet and I accept responsibility for all accumulated fees associated with the care that my pet(s) receive. I understand that I am responsible for payment in full prior to discharge according to Desoto County Animal Clinic policy and will be held responsible for service or collection fees if balance is not paid in full.
Client Signature
Date
MM slash DD slash YYYY
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