Hampden Vet Clinic| New Client Form

HAMPDEN VETERINARY CLINIC

keeping your pet happy and healthy

Hampden Veterinary Clinic
5 Allen Street
Hampden, MA 01036
(413)566-2455

NEW CLIENT

Name: *
E-mail Address: *
Street Address:

City: *
State: *
Zip Code: *
Pets Name: *
Sex: *	Male Female
Age: Years/months *
Type of Pet: *

Breed:
Neutered or Spayed? *	Yes, neutered or spayed No, not neutered or spayed
Are your pets vaccines current? *	Yes No
Do you have pets medical records? *	Yes No
Are the medical records at another veterinary Practice?	Yes No
Name of Former Veterinary Practice:
May we request a transfer of records?	Yes No
Would you like us to call you for your appointment?	Yes No
Phone Type: *
Phone Number: *
Reasons or conditions that prompted your visit?

Special requests or 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 Hampden Veterinary Clinic 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 finance charge of 1.5% or 18% per annum. Any balance that I leave unpaid will be forwarded to Hampden Veterinary Clinics 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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