New Client Form Please enable JavaScript in your browser to complete this form. Name * First Last Address * Address Line 1 Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState Zip Code Daytime Phone * Evening Phone E-mail * Pet Name Pet's Age: Years, Month Species * Dog Cat Avian Exotic Other If other, please specify. Breed Sex * Male Male – Neutered Female Female – Spayed Are your pet(s) vaccines current? Yes No Do you have your pet(s) medical records? Yes No Medical records at another veterinary Practice? Yes No Name of Former Veterinary Practice: May we request a transfer of records? Yes No How did you hear about us? Who may we thank? Special requests or conditions? Please list any additional pets here: I understand, by indicating I agree and submitting this registration, that I am responsible for any charges incurred by my pet while in the care of the doctors at Castle Pines Veterinary Hospital and that charges are due and payable at the time of service, unless other arrangements are made in advance. Any balance that is carried over a period of 30 days will accrue a monthly finance charge of 1.5% or 18% per annum. Any balance that I leave unpaid will be forwarded to Castle Pines Veterinary Hospital's collection agency, and will incur a 25% collection fee for which I am liable, in addition to monthly finance charges. In the unlikely event your account goes unpaid and is placed for collections, you agree to pay all costs of collections, attorney fees and court cost. I have read this statement and: I agree I disagree Digital Signature * Today's Date * Name Submit
