Powell Animal Hospital

Hours Mon-Fri 7:30 AM to 7:00 PM, Sat 9:00AM to 5:00 PM 

Free doses and rebates with purchase of Frontline and Heartgard
     

New Client Check In

If you would like to make an appointment, you can help us to expedite your check in by submitting this form.

Thank you for your co-operation in letting us assist you.

Form - New Client

Name (required)
First Name (required)
Last Name (required)
Address (required)
Street Address (required)
City (required)
State/Province (required)
Zip/Postal Code (required)
,
Daytime Phone (required)
Phone TypePhone Number (required)
Evening Phone (required)
Phone TypePhone Number (required)
E-Mail Address :
Do you prefer to receive reminders by e-mail or postcards?
E-mail
Postcards

How did you learn about our hospital? :
If you learned about us from one of our current clients, whom may we thank for the referral?

Pet's Name: (required)

Age: Years, Months

Type of Pet: (required) :
Breed:

Color:

Sex: (required)
Male
Female

Neutered/Spayed:
Neutered
Spayed

Please list all vaccines that your pet has had and when they were last administered:

Do you have your pet's medical records?
Name and Phone Number of Former Veterinary Practice:

May we request a transfer of records?
Yes
No

Would you like us to call you to set up an appointment?
Reasons or conditions that prompted your visit:

Please list any allergies or previously diagnosed medical conditions:

Please list any additional pets:

Please Read
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 Powell Animal 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 billing charge and a monthly finance charge of 1.5% or 18% per annum. Any balance that I leave unpaid will be forwarded to Powell Animal Hospital's collection agency, and will incur a 25% collection fee for which I am liable, in addition to monthly finance charges.
I have read this statement and -
I Agree
I Disagree


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