New Client Form No appointment yet? Be sure to book your appointment here first!Owner's Name First Middle Last Home PhoneWork PhoneCell PhoneSMS consent I consent to receive SMS text messages from Colonial Animal Hospital. Msg & data rates may apply. Reply STOP to opt out.Email Spouse/Partner/Co-Owner's Name First Middle Last Home PhoneWork PhoneCell PhoneAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code How did you learn of our hospital? Yellow Pages Web Site Location/Sign Referred By Friend OtherIf referred by friend, their name so we can thank themPROFESSIONAL FEES ARE TO BE PAID AT THE TIME SERVICES ARE PERFORMEDFor your convenience we accept cash, checks and major credit cards. With prior approval, we also offer a choice of No Interest Payment Plans to qualified applicants through our financial partner CareCredit. Please ask us in advance of your procedures if you are interested in applying for CareCredit.In admitting my pet(s) for diagnostics, treatment or surgery, I authorize the veterinarians of COLONIAL ANIMAL HOSPITAL, and their support staff, to administer such treatment and/or perform such diagnostic or surgical procedures as deemed necessary.It is understood that an estimate of charges will be given for services. No guarantee or assurance can be made as to the results that may be obtained.Further, I understood that a deposit of 50% is required before services are performed and I assume full financial responsibility for all charges incurred by my pet and understand that full payment is required upon discharge. I realize that these charges may exceed a given estimate if complications arise. I understand that I will be contacted prior to treatment, if possible, should complications occur. In case of non-payment, I am aware that I will be charged by Colonial Animal Hospital, the actual cost of collection, including, but not limited to attorney’s fees, court costs, plus interest and administrative fees in addition to the amount owed for services.SignatureDate MM slash DD slash YYYY Pet 1Pet's NameSpeciesBirth Date MM slash DD slash YYYY Sex Male FemaleSpayed/Neutered? Yes No Not sureColorDo you have a second pet? Yes NoPet 2Pet's NameSpeciesBirth Date MM slash DD slash YYYY Sex Male FemaleSpayed/Neutered? Yes No Not sureColorDo you have a third pet? Yes NoPet 3Pet's NameSpeciesBirth Date MM slash DD slash YYYY Sex Male FemaleSpayed/Neutered? Yes No Not sureColorDo you have a fourth pet? Yes NoPet 4Pet's NameSpeciesBirth Date MM slash DD slash YYYY Sex Male FemaleSpayed/Neutered? Yes No Not sureColorDo you have a fifth pet? Yes NoPet 5Pet's NameSpeciesBirth Date MM slash DD slash YYYY Sex Male FemaleSpayed/Neutered? Yes No Not sureColorCAPTCHAΔ
