New Clients Save $15 on Wellness Exams with Dr. Lopez & Dr. Burgess! Schedule Online or Call Now!

New Client Form

Get Started

New Client Form

Name *

First

Last

Email *

Primary Phone *

Secondary 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? *

Reason for Visit *

List your pet's previous veterinarian

Payment is due in full at the time that services are performed. If being admitted into the hospital, we cannot begin the care of your Pet until you have confirmed your desire to do so by 1) signing the client consent & estimate form, and 2) leaving an initial deposit of 50% of the upper end of the estimate. This is the only way that we have of knowing for certain that you want us to proceed with the care of your Pet. We accept Cash, Check, Visa, MasterCard, Discover, and CareCredit payments. We neither extend credit, nor bill for services. All open invoices are sent to collections after 45 days unless prior arrangements are made. *

I have read and accept the financial policy.

Upload Previous Medical Records

Click or drag files to this area to upload. You can upload up to 5 files.

Name

New Client Form

New Client Form

Come Visit Us

Hours

After-Hour Emergency Care

Have a Question?