We are accepting new clients! Please complete our New Client Form, and a member of our team will reach out to schedule your appointment.

New Client Form

Please fill out this form as completely and accurately as possible so we can get to know you and your pet(s) before your visit. You can also download the form and email it to us by clicking the button below.

Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Email *

Primary Phone *

What type of phone it is? *

Cell Phone
House Phone

Who else is authorized to make decisions about your pet's healthcare? *

First

Last

Secondary Phone

What type of phone it is? *

Cell Phone
House Phone

Spouse/Partner/Co-Owner's Phone

How did you learn of our hospital? *

Saw Our Hospital / Location
Google (or other search)
Yellow Pages (print)
Facebook
Online Review Site
Client Referral
Other

If Other, please explain.

What social media platforms do you use?

Facebook
Twitter
Pinterest
Instagram
LinkedIn
Google+

Other information the office should know?

FINANCIAL POLICY: Our office accepts Visa, Mastercard, Discover and Care Credit, along with cash and checks (only with current DL information on file). Full payment is due at the time of service. Clients with payment concerns are asked to speak to a Client Service Representative before their exam. Our staff is happy to provide any client with a written treatment plan prior to services being rendered. Client will be responsible for a 1.5% monthly finance charge on accounts over 30 days and any collection fees on accounts over 90 days. As of September 1, 2015, we offer 6 months, no interest financing via Care Credit for clients in need a credit plan. No other payment plans are offered at this time. Your signature below indicates your agreement with this policy. *

I have read and understand

TREATMENT CONSENT: I hereby authorize the veterinarian to examine, prescribe for or treat the below-described pet(s) to the best of their abilities. I assume responsibility for all charges incurred in the care of this animal. I acknowledge that medical information will not be released to anyone not indicated on this form without my express permission. *

I have read and understand

We love social media! Do we have your permission to share your pet(s)’ image and story on social media, our website & other forms of related media? *

Today's Date *

Pet #1

Pet's Name *

Species (dog, cat, etc.) *

Breed *

Age/Date of Birth *

Color/Markings:

Vaccinations were last given by (clinic name)

Allergies or Long-term Medical Problems:

Sex *

Male
Neutered Male
Female
Spayed Female

Do you a second pet to add?

Pet #2

Pet's Name *

Species (dog, cat, etc.) *

Breed *

Age/Date of Birth *

Color/Markings:

Vaccinations were last given by (clinic name)

Allergies or Long-term Medical Problems:

Sex *

Male
Neutered Male
Female
Spayed Female

Do you a third pet to add?

Pet #3

Pet's Name *

Species (dog, cat, etc.) *

Breed *

Age/Date of Birth *

Color/Markings:

Vaccinations were last given by (clinic name)

Allergies or Long-term Medical Problems:

Sex *

Male
Neutered Male
Female
Spayed Female

Do you a fourth pet to add?

Pet #4

Pet's Name *

Species (dog, cat, etc.) *

Breed *

Age/Date of Birth *

Color/Markings:

Vaccinations were last given by (clinic name)

Allergies or Long-term Medical Problems:

Sex *

Male
Neutered Male
Female
Spayed Female

Phone

Visit Clinton Veterinary Hospital

The Clinton Veterinary Hospital in Clinton, CT proudly serves the pets of Madison, Guilford, Clinton, Westbrook, Deep River, Old Saybrook, Chester, Ivoryton, Essex, and Killingworth. We look forward to seeing you and your pet. You may request an appointment by clicking the button below.

Book Appointment