New Client Form

Please complete the form below prior to your first appointment.

APPOINTMENT

Name *

First

Last

Email *

Primary Phone *

Secondary Phone

Spouse/Co-Owner Name

First

Last

Spouse/Co-Owner Phone

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Who else is authorized to make decisions about your pet's healthcare? *

First

Last

Phone

How did you find out about our hospital? If you were referred by someone, who should we thank? *

Pet's Name *

Species (dog, cat, etc.) *

Breed *

Age/Date of Birth *

Sex *

Male
Neutered Male
Female
Spayed Female

Does your pet have a microchip identification? *

Place of Last Vaccinations

Please list any current medications.

I attest that I am over the age of 19 and the legal owner of the pet(s) listed above. I hereby authorize the veterinarians of Companion’s Choice Animal Hospital to examine, prescribe for, and/or treat my pet(s). I assume responsibility for all charges incurred in the care of this animal. I also understand that these charges will be paid at the time of the release and a deposit may be required to hospitalize my pet(s) and/or provide surgical treatment/care. I understand that as a new client, I will be required to place a $50 deposit on my account to schedule an anesthetic event. The deposit is nonrefundable if I cancel or reschedule the appointment within 24 hours of the event. If I show up on time to the scheduled event, the deposit will offset charges incurred. *

I have read and accept.

Signature *

Clear Signature

Date *

Comment

New Client Form

We proudly serve the pets Hastings, NE and beyond.

Contact

Location

Hours

Boarding Hours

Have a question?

Book Your Next Appointment Online!

Use our online appointment request form to book your next appointment online in minutes.