Grandview Animal Hospital - New Client Check-in Form. GRANDVIEWVET.COM

PH: (816) 761-5071 FAX: (816) 761-2511
1006 Main Street Grandview, MO 64030
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NEW CLIENT CHECK-IN FORM

You can assist us to expedite your check-in by submitting this form.

After filling out the form below, contact us by phone at 816-761-5071 or via email to schedule your appointment.

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 Type	Phone Number (required)

Evening Phone (required)
Phone Type	Phone Number (required)

Would you like us to call you for your appointment?
Yes
No

E-Mail Address :

If you were referred, whom may we thank?

Pet's Name (required)

Age: Years, Months

Type of Pet (required) :

Breed:

Sex: (required)
Male
Female

Is your pet Neutered or Spayed?
Neutered (Male)
Spayed (Female)

Are your pet's vaccines current?
Yes
No

Do you have your pet's medical records?
Yes
No

Medical records at another Veterinary Practice?
Yes
No

Name of Former Veterinary Practice:

May we request a transfer of records?
Yes
No

Reasons or conditions that prompted your visit?

Special requests or conditions?

Please list any additional pets here:

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 Grandview 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 finance charge of 1.5% or 18% per annum. Any balance that I leave unpaid will be forwarded to Grandview 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 - (required)
I Agree
I Disagree

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