New Client Form in East Lansing

We know your pet’s health is important and we than you for trusting us to care for them. To help us provide the best care possible, please take a few moments to fill out this confidential form completely. Thank You!

New Client Form

This form is for new clients only and should not be used to request an appointment.

Pet Owner's Name
Pet Owner's Name
First Name
Last Name
Spouse/Other Name
Spouse/Other Name
First Name
Last Name
Address
Address
City
State/Province
Zip/Postal
Emergency Contact Name
Emergency Contact Name
First Name
Last Name
How did you learn about our clinic?
Species
Please Indicate If Your Pet Is...

Authorization

Please choose one

It is our policy to obtain owner consent prior to consulting with any organization or individual regarding pet adoption eligibility. Please contact us to authorize disclosure of information under these circumstances.

I hereby authorize the veterinarian to examine, prescribe for, and/or treat the above described pet. I assume full responsibility for all charges incurred for the care of this animal. I also understand that these charges will be paid at the time of release and that a deposit may be required for surgical treatment and also that any outstanding balance on my account will incur monthly interest at 1.5% and a billing fee of $2.00

I give Eastside Animal Hospital permission to use photos of my pet online and in advertising.