New Client Form – Beisinger Veterinary Services

The New Client Form can be completed online below, or you can download the PDF version and fill out at your leisure. Please remember to bring a completed form to your appointment.

First Name:
Last Name:
Secondary First Name:
Secondary Last Name:

Address:
City:
State:
Zip Code:

Primary Phone:
Secondary Phone:
Email:
Occupation:
Employer:
Date of Birth:
Driver's License:

Preferred method of contact: EmailPhone

Patient Information:

Name:
Sex: FemaleMale
Patient is: CanineFeline
Breed:
Date of Birth:
Age:
Microchip/Tattoo#:
Any known allergies or major medical issues?

FOR YOUR INFORMATION:

1. I am the owner of the patient(s) on this form. I have the authorization to consent and enter into agreement for treatment if/and when it is needed.

2. I understand that all fees are to be paid at the time of services. I understand that I can pay by Mastercard, Visa, Discover, Care Credit, or cash.

3. I understand that Beisinger Veterinary Services has the right to refuse me service if I am in anyway rude, threatening, or disrespectful at any time.