New Client Form Welcome to Coral Springs Animal Hospital! To help us prepare for your pet’s first visit, please complete the form below. This information allows our team to provide a smoother check-in process and personalized care from the start. New Client Form Name * Name First First Last Last Email * Primary Phone * Secondary Phone Address * Address Address Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Who else is authorized to make decisions about your pet's healthcare? Who else is authorized to make decisions about your pet's healthcare? First Name First Name Last Name Last Name Their Phone Number Pet's Name * Species * Breed * Pet's Color * Age/Date of Birth * Sex * MaleNeutered MaleFemaleSpayed Female Does your pet have a microchip identification? * Yes No What is the microchip number? Payment is due in full at the time that services are performed. If being admitted into the hospital, we cannot begin the care of your Pet until you have confirmed your desire to do so by 1) signing the client consent & estimate form, and 2) leaving an initial 75% deposit at the time of admission. This is the only way that we have of knowing for certain that you want us to proceed with the care of your Pet. We accept Cash, Visa, MasterCard, Discover, WellsFargo credit card, Scratch Pay, and CareCredit payments. We neither extend credit, nor bill for services. All open invoices are sent to collections after 45 days unless prior arrangements are made. * Consent * I have read and accept the financial policy. Signature * signature keyboard Clear Date * Captcha Submit If you are human, leave this field blank.
