New Client Form New Client Form Owner Information Name * Name First Name First Name Last Name Last Name Email * Phone * Would you like to opt in to receive text messages from Case Veterinary Hospital? * Yes No Are you in the military? * Yes No Address * Address Address Address City City State/Province State/Province Zip/Postal Zip/Postal Country AfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCôte d'IvoireCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCroatiaCubaCuracaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSaint BarthelemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Who else is authorized to make decisions about your pet's healthcare? * Their Phone Number: * How did you find out about our hospital? * Google/Search EngineFriend/FamilyVeterinary HospitalEmployeeSocial MediaCommunity EventDrive By/LocationOther If other, please specify. * If you were referred by someone, who should we thank? * Pet Information Pet's Name * Species * Cat Dog Other Breed * Color * Age/Date of Birth * Sex * Male Female Unknown Does your pet have a microchip identification? * Yes No Add Another Pet? * Yes No Pet Information Pet's Name * Species * Cat Dog Other Breed * Color * Age/Date of Birth * Sex * Male Female Unknown Does your pet have a microchip identification? * Yes No To help us make your pet’s visit as low-stress and comfortable as possible, please answer the following: Has your pet ever shown signs of fear, anxiety, or stress during a veterinary visit? Yes No If yes, please describe: Has your pet ever received sedatives or calming doses before a vet or grooming visit? * Yes No If yes, which dose(s) and how did they work? At Case, we have several team members trained in low-stress handling techniques. If you're interested, we can customize your pet's visit using these methods. This approach may involve more time, acclimation sessions, or multiple visits—and may result in additional fees. If that’s not the right fit, we’re also happy to discuss pre-visit calming doses. Please let us know what you’re most comfortable with: Low-stress handling approach Pre-visit calming medications Not sure—please discuss options with me Do you have pet insurance? Yes No If yes, what company is the policy with? Please upload any copies of your pet's records here, if possible. Drop a file here or click to upload Choose File Maximum file size: 52.43MB Payment is due in full at the time services are performed or upon the release of your pet. We accept cash, debit cards, Visa, Mastercard, American Express, and Discover. A 2.6% surcharge applies to all credit card payments. We encourage clients to pay with cash or a debit card to avoid this fee. Payment plan options are available through CareCredit, Cherry, and VetBilling. We do not extend in-house credit or bill for services. If your pet is admitted to the hospital, treatment cannot begin until you have: Signed the Client Consent & Estimate Form; and Paid an initial deposit equal to 50% of the upper end of the estimate. Any outstanding balance may be subject to a finance charge. Open invoices may be sent to collections after 45 days unless prior arrangements have been made. We request at least 24 hours’ notice when canceling an appointment. Cancellations made without the required notice may be subject to a cancellation fee. By signing below, you acknowledge that you understand and agree to this payment policy and authorize Case Veterinary Hospital to provide care and treatment for your pet(s). * I have read and accept the financial policy. I give you permission to medically treat my pet. I consent to have my pet’s picture used by Case Veterinary Hospital, and I understand the following: My pet’s picture may be used on Case Veterinary Hospital’s website, Facebook, Instagram or any media site that suits the Hospital. I can withdraw my consent at any time I will receive no compensation for my consent I understand pictures may be copied and used by Case Veterinary Hospital without further permission. * Yes, I consent No, I do not consent I confirm that all information submitted on this form is correct to the best of my knowledge. * signature keyboard Clear Submit If you are human, leave this field blank.
