E-mail Address : How did you hear about us? (required) Current Client or Personal Recommendation Google or Internet Search Humane Society or Rescue Our Location or Sign Phone Book/Advertisement OtherIf you selected Current Client or Other please list the name of the person or source. Pet Information
Pet's Name (required) Species (required) : Please Select Canine Feline Avian Exotic Other Breed (required) Color (required) Age: Years & Months or Date of Birth Sex (required) : Please Select Male Female Is this pet spayed or neutered? (required) : Please Select Yes No Not old enough I'm not sure Is this pet microchipped? (required) : Please Select Yes No Unknown If yes, please enter the microchip number below: Does this pet have any allergies to medications or vaccinations? (required) : Please Select Yes No Unknown If yes, please list your pet's allergies. Please list any health conditions or important notes regarding your pet. Please list any additional pet(s) that you would like us to add to your file. Please list the name and phone number of your previous veterinary clinic(s). May we contact the clinic(s) listed above to obtain your pet's medical records? : Please Select Yes No Would you like a staff member to contact you to schedule an appointment? (required) : Please Select Yes No I already made one! Important Information
Payment is due at the time services are rendered. Please indicate how you plan to pay. We do not accept personal checks. (required) : Please Select Credit/Debit Card Cash Care Credit By selecting "I Agree" below and submitting this New Client Form I am requesting veterinary care for my pet(s) and understand I am financially responsible for any charges incurred by and for my pet(s) at Eagan Pet Clinic (EPC). I agree that if I do not pay my balance as agreed, my account is subject to collection fees, attorney fees, interest and any fees associated with collecting a debt. Eagan Pet Clinic does not accept checks, but in the event an exception is made and my check is returned, returned checks are subject to a $30 fee per returned check.
I grant Eagan Pet Clinic the right to take photographs of my pet in connection with their business. I agree that EPC may use photographs of my pet(s) for any lawful purpose, including online, in print, in marketing or any other business related use. I have read the above statement and - (required) : Please Select I Agree I Disagree