New Client FormBefore filling out the new client form below, we ask that you please call us first to schedule your appointment. You can reach us 209-951-5180. We look forward to hearing from you!TitleDr.Mr.Mrs.Ms.MissName(Required) First Last Address(Required) Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home PhoneCell Phone(Required)Email(Required) Owner’s Birthdate(Required) MM slash DD slash YYYY Needed for Controlled SubstancesPreferred Method of Contact Email Text MailEmployerEmployer TelephoneOccupationTitleDr.Mr.Mrs.Ms.MissSpouse/Significant Other’s Name First Last Cell PhoneBirthdate MM slash DD slash YYYY Needed for Controlled SubstancesEmergency Contact Name(Required) First Last Phone Number(Required)Village Veterinary Hospital and Companion Animal Eye Care requires payment in full at the end of your pet’s examination and/or at the time of discharge. For some treatment or hospitalized care, a deposit is required. Healthcare plans requiring comprehensive care of more than $500, will require a 50% deposit to begin your pet’s treatment.Payment forms accepted: Cash, Visa, Mastercard, American Express, Discover, and Care Credit.WE DO NOT ACCEPT CHECKS.Veterinarian Referral(Companion Animal Eye Care patients only)Pet InformationName(Required)Species(Required) Dog CatSex(Required) Male FemaleAltered(Required) Yes NoBreed(Required)Color(Required)Birthdate(Required) MM slash DD slash YYYY TemperamentAdd another pet? Yes NoPet #2 Name(Required)Species Dog CatSex Male FemaleAltered Yes NoBreedColorBirthdate MM slash DD slash YYYY TemperamentAdd another pet? Yes NoPet #3 NameSpecies Dog CatSex Male FemaleAltered Yes NoBreedColorBirthdate MM slash DD slash YYYY TemperamentWhat are you looking for out of your veterinarian?I, the undersigned owner or authorized agent of the above patient(s), hereby authorize the doctors of Village Veterinary Hospital and Companion Animal Eye Care to administer such treatment as is necessary. I understand that in accordance with section 18.34 of the California Civil Code, if the owner of any animal left in the hospital is not picked up within 14 days after the day the animal is to be released the animal shall be deemed abandoned.* I Agree to the Terms Listed Above.I, the undersigned owner or authorized agent of the above patient(s), hereby authorize the doctors of Village Veterinary Hospital and Companion Animal Eye Care to administer such treatment as is necessary. I understand that in accordance with section 18.34 of the California Civil Code, if the owner of any animal left in the hospital is not picked up within 14 days after the day the animal is to be released the animal shall be deemed abandoned.* I agree to the terms listed aboveYes, I have already called Village Veterinary Hospital and scheduled my appointment. *Note: You will not able to submit this form until you have scheduled an appointment and check this box as complete.(Required) YesAttach pet records hereMax. file size: 128 MB.Signature(Required)Δ
