New Client Form - Claremore Vet | Animal Medical Center

Owner Name*
Date
Address*
Street Address Address Line 2 City State ZIP Code
Home Number
Cell Number*
Email Address
Driver's License Information
Driver's License Number State of Issue Expiration Date
Date of Birth
Place of Employment
Phone
Spouse's Place of Employment
Phone
In Case of Emergency, whom may we contact?
Phone
How did you hear about us?
We no longer accept checks or American Express
Method of Payment
- Cash
- Visa
- MasterCard
- Discover
Payment Policy:
All professional service charges are due at the time rendered. Deposits are required on major medical/surgical cases, trauma cases, emergency work, and hospitalized and/or boarding patients. We proudly accept Cash, Visa, MasterCard, and Discover.

First Pet
Select One:*
- Dog
- Cat
Pet Information
Name Breed Microchip# Date of Birth Color Sex Spayed or Neutered
Second Pet
Select One:
- Dog
- Cat
Pet Information
Name Breed Microchip# Date of Birth Color Sex Spayed or Neutered
Third Pet
Select One:
- Dog
- Cat
Pet Information
Name Breed Microchip# Date of Birth Color Sex Spayed or Neutered

I/we hereby authorize the veterinarians to examine, prescribe for, or treat my pets (s). I/we assume full responsibility for all charges incurred in the care of this/these animal(s). I/we also understand that these charges will be paid in full at the time of release and that a deposit may be required for certain surgical treatments or other procedures.
Type Signature
Name
This field is for validation purposes and should be left unchanged.

We no longer accept checks or American Express