NEW CLIENT INFORMATION
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Thank you for giving us the opportunity to care for your pet.
Please take the time to fill in the new client information form completely.

NEW CLIENT INFORMATION

Address:

Additional Authorized Contact Name and Number:

You authorize us to speak to this person about your pet’s care in the event we cannot reach you.
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NEW PATIENT INFORMATION

Dog Cat
Dog Cat
Male Neutered Female Spayed
Male Neutered Female Spayed

Yes, Please make my pet a star! No, Thank you

If you must cancel an appointment, we ask for 24 hours’ notice. If cancelling a surgical appointment, we ask for 48 hours’notice. A late cancellation or frequent cancellations may result in a fee being applied to your account.

Current vaccinations are required by Bellevue Animal Hospital before we may admit any animal for any reason. These measures are taken to protect the well-being of all animals within our hospital.

I hereby authorize the veterinarian to examine, prescribe for or treat the above described pet(s). I assume responsibility for all charges incurred in the care of this animal. I understand that payment is always due in full at the time of service.
I recognize that financial concerns should be discussed prior to exam and treatment. For your convenience we accept Visa, Mastercard, American Express, cash and checks with proper identification. Please stop at the reception desk to review and pay for services.
I confirm that the above information is correct and that I am the owner or authorized agent of the patient(s) listed above.