New Client Information Form

Client Information

Note: if there is a field not applicable to you, please fill in with N/A.

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Owner's Name(Required)



Emergency Contact Person

How did you first hear about us?(Required)

Patient Information




Is your pet(s) currently protected against heartworm disease?(Required)

Is your pet(s) currently protected against fleas/ticks?(Required)

I, the undersigned, authorize the veterinarian(s) and staff employed by Old Mill Veterinary Hospital to examine, prescribe for and treat accordingly up to and including medical surgical procedures for the patient/s specifically described and identified above.

I assume responsibility for all charges incurred for services rendered to the patient/s.

Also, I understand payment is due when services are rendered. Deposits may be required for some services.

There are additional fees assessed for non-payment, returned checks and accounts sent to collection. I understand and agree to pay these fees.

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