New Client Form in Southaven, MS | Desoto County Animal Clinic

Date

Date Format: 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?

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

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Pet 2

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