New Client Registration First Name * Required Last Name * Required Appointment Date * Required MM slash DD slash YYYY Time * Required : Hours Minutes AM/PM AM PM AM/PM Address Street Address City State / Province / Region ZIP / Postal Code Phone * RequiredEmail * Required How did you hear about us? * Required Preferred Method of Contact * Required Email Phone PET INFORMATIONName * Required Breed * Required DOB or Age * Required Color * Required Weight * Required Allergy * Required Sex * Required Male Female Spayed/Neutered * Required Yes No Date of last vaccination * Required MM slash DD slash YYYY Are there any health concerns we should know about? * RequiredPrevious or Referring Veterinarian * Required Practice Name * Required Address Street Address City State / Province / Region ZIP / Postal Code Would you like us to get a copy of your pet’s records from this Veterinarian? If so, please authorize below: I request that a copy of all medical records from the above named veterinarian for my animal(s) be released to Valley Oak Veterinary Clinic, Inc. at fax # 408-956-8329. I, the owner of the above named animal(s), understand and agree that the account balance is due in full upon receipt of services at Valley Oak Veterinary Clinic. * Required EMERGENCY SERVICES: A DEPOSIT WILL BE REQUIRED BEFORE WE WILL BEGIN A TREATMENT PLAN. Payment methods accepted: Cash, Personal Check (Established clients only), Visa, Mastercard, Discover, or Debit Card. YOU AGREE TO REIMBURSE US THE COLLECTION FEES OF ANY COLLECTION AGENCY, WHICH SHALL BE BASED ON A PERCENTAGE AT A MAXIMUM RATE OF 33 1/3% OF THE AMOUNT DUE AT THE TIME YOUR ACCOUNT IS PLACED WITH A COLLECTION AGENCY, AND ALL COSTS AND EXPENSES INCURRED FOR ANY COLLECTION EFFORTS ON YOUR ACCOUNT, INCLUDING REASONABLE ATTORNEY’S FEES INCURRED BY THE COLLECTION AGENCY. THIS CONTRACT SHALL COVER ALL MEDICAL TREATMENT AND SERVICES UNTIL REVOKED BY EITHER PARTY IN WRITING. Δ
