New Client Form

First name

Last name

Email address

Primary phone number

If the primary phone is a cell phone, please enter the cell phone provider (optional)

Alternate phone number (optional)

Significant other name (optional)

Significant other phone number (optional)

Address

City

State
---AlaskaAlabamaArkansasArizonaCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIowaIdahoIllinoisIndianaKansasKentuckyLouisianaMassachusettsMarylandMaineMichiganMinnesotaMissouriMississippiMontanaNorth CarolinaNorth DakotaNebraskaNew HampshireNew JerseyNew MexicoNevadaNew YorkOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVirginiaVermontWashingtonWisconsinWest VirginiaWyoming

Zip code

Emergency contact name

Emergency contact phone number

How did you hear about us?

Method of payment
---CashCredit cardCare credit

Please note our hospital's financial policies

1. Payment is due, in full, at the conclusion of the visit or service. WE DO NOT BILL. We accept Care Credit, cash and credit cards. We do not extend credit or arrange payment terms. All hospital or surgical estimates are to be paid in full at completion of service.
2. Failure to pay will result in full collection efforts being taken and the customer will be responsible for all collection costs including, but not limited to, court costs, serving by private processor or Sheriff, and any other fees incurred.

Whole Pet Wellness Center offers excellent veterinary care at value-driven prices. We sincerely hope you understand our policies as they are in place to keep your veterinary medical expenses at a reasonable rate.

I have read the above reference policies. I understand them completely and give notice of my intention to fully adhere to their provisions.

Your initials