New Client Form - Jackson Hwy Veterinary Clinic

Date(Required)

Name(Required)

First Last

Mailing Address(Required)

Street Address Address Line 2 City State ZIP Code

Phone(Required)

Additional Phone(Required)

Driver's License(Required)

Email(Required)

Spouse or other contact information

Must be over 18 years old to authorize treatment

Secondary Contact Name

First Last

Secondary Contact Phone

Relationship

An updated Rabies vaccine is required at the time of the exam or can be performed during the exam or prior to surgery for the day!(Required)

I understand

Do you carry CareCredit credit card? Unlike traditional pet financing the CareCredit credit card gives you the flexibility to use your card again and again for your pet's procedures. You can apply here at Jackson Hwy Vet Clinic, just ask a receptionist how!(Required)

Yes

I hereby authorize the Veterinarians at Jackson Hwy Vet Clinic to examine, prescribe for, and or to treat my pets. I also agree that the above information is true.(Required)

I authorize and agree

I AM FINANCIALLY RESPONSIBLE FOR ALL CHARGES INCURRED IN THE CARE OF MY PETS. I ALSO UNDERSTAND THAT THESE CHARGES WILL BE PAID AT THE TIME OF SERVICES RENDERED AND THAT 50% DEPOSIT WILL BE REQUIRED FOR COMPLICATED AND OR SURGICAL TREATMENTS.(Required)

I understand

Signature(Required)

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