Client Information

Name *

First

Last

Spouse

Mailing address *

Address Line 1

Address Line 2

City

State

Zip Code

Primary Phone *

Secondary Phone

Email address *

Employer *

I grant Parvin Animal Clinic permission to use my pet’s pictures, medical information, and story on social media. *

Yes
No

Patient Information

Pet's Name *

Sex *

Male
Neutered Male
Female
Spayed Female

Species *

Dog
Cat

Pet's Date of Birth *

Breed *

Color *

Microchipped? *

Yes
No

What is the microchip number?

Would you like to add a second pet? *

Yes
No

Pet's Name *

Sex *

Male
Neutered Male
Female
Spayed Female

Species *

Dog
Cat

Pet's Date of Birth *

Breed *

Color *

may Do your

Microchipped? *

Yes
No

What is the microchip number?

Would you like to add a third pet? *

Yes
No

Pet's Name *

Sex *

Male
Neutered Male
Female
Spayed Female

Species *

Dog
Cat

Pet's Date of Birth *

Breed *

Color *

Microchipped? *

Yes
No

What is the microchip number?

Do your pet(s) have any allergies, special medications, or health problems we should know about? *

Yes
No

Please specify.

What type of food do your pet(s) eat? *

Treats?

Are your pets on heartworm preventatives? *

Yes
No

Which one?

Last date given?

Are your pets on flea prevention? *

Yes
No

Which one?

Last date given?

Who was your previous veterinarian?

Phone

How did you hear about our hospital?

Whom may we thank?

In order to provide exceptional service to our clients and their families, our office implements a cancellation and no-show policy. Parvin Animal Clinic requests at least a 48-hour (2 business days) notice of changes or cancellations to scheduled surgeries, dental procedures, and ultrasounds. We request at least a 24-hour (1 business day) notice of any changes or cancellations to scheduled appointments. Changes outside of the above windows, late cancellations, or not showing for scheduled procedures and/or appointments may result in a charge. As a courtesy to our clients and patients, we offer an automated confirmation system, by utilizing the contact information listed above.

Parvin Animal Clinic requires a deposit fee of $150.00 at the time of scheduling for all elective surgeries, dental procedures, and ultrasounds. All non-elective procedure deposits are varied based on the procedure required. This deposit reserves the patient’s slot for the desired date of his/her procedure and will be used towards the services rendered that day. In the event of a late cancellation/late reschedule and/or a no-show on the day of the procedure, this deposited will be forfeited.
All services must be paid at the time services are rendered.
All emergencies and/or hospitalization require a deposit of at least 50% of the estimated cost. This deposit is due at the time the patient is admitted and prior to any medical treatments taking place.

Date *

Owner’s Signature *

Clear Signature

For your convenience, we accept cash, MasterCard, Visa, Discover, American Express, Care Credit, and ScratchPay. By signing, I verify that all the information provided is accurate and promise to inform the staff at Parvin Animal Clinic of any and all financial concerns involving payment beforehand.

New Client Form

New Client Form for Parvin Animal Clinic in Spanish Fort, AL

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Patient Information

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