New Client

Sit. Stay. Heal.

Animal Care Center
1281 East Napier Ave.
Benton Harbor, MI 49022
(269) 926-2381

New Client Check In

If you would like to make an appointment, you can assist us to expedite your check in by submitting this form.

Thank you for your cooporation in letting us assist you.

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)

E-Mail Address (required) :

Employer (required)

Occupation (required)

Pet's Name (required)

Age: Years, Months

Type of Pet (required) :

Breed:

Sex: (required)
Male
Female

Neutered/Spayed
Neutered
Spayed

Are your pets vaccines current?

Do you have pets medical records?

Medical records at another veterinary practice?
Yes
No

Name and phone # of former veterinary practice

May we request a transfer of records?
Yes
No

Check this box if you would like us to call you for your appointment

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 Animal Care Center and that charges are due and payable at the time of service. An estimates for charges can be provided, but I realize that charges may exceed a given estimate if complications arise. By admitting my pet(s) for diagnostics, treatment, or surgery, I authorize the veterinarians of Animal Care Center and their support staff, to administer such treatment and/or perform such diagnostic or surgical procedures as deemed necessary.

I have read this statement and - (required)
I Agree
I Disagree

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