Eagan Pet Clinic

4395 Rahn Rd
Eagan, MN 55122

(651)454-5684

www.eaganpetclinic.com

New Client Form

All new clients are required to fill out a New Client Form. By filling out this form online you can save yourself some time at your first appointment. You may still be asked to sign a paper copy of the form and verify that the information is correct.

**If you have more than one pet, please fill out multiple forms.**

You will receive a confirmation on this page when your form is successfully submitted.

Thank you!

New Client

Owner Name (required)

First Name (required)	Last Name (required)

Co-Owner Name (Spouse, Friend, Child, etc.)

First Name	Last Name

Address & E-mail (required)
Street Address (required)

City (required) ,	State / Province (required)	Zip / Postal Code (required)

E-mail Address :

Primary Phone (required)
Phone Type	Phone Number (required)

Other Phone
Phone Type	Phone Number

Co-Owner Phone
Phone Type	Phone Number

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
Other

If you selected Current Client or Other please list the name of the person or source.

Pet Information

Pet's Name (required)

Species (required) :

Breed (required)

Color (required)

Age: Years & Months or Date of Birth

Sex (required) :

Is this pet spayed or neutered? (required) :

Is this pet microchipped? (required) :

If yes, please enter the microchip number below:

Does this pet have any allergies to medications or vaccinations? (required) :

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? :

Would you like a staff member to contact you to schedule an appointment? (required) :

Important Information

Payment is due at the time services are rendered. Please indicate how you plan to pay. (required) :

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. 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) :

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