Thank you for giving us the opportunity and care for your pet. Please take time to fill out this form completely.

Owner's Name *

First

Last

Spouse's Name

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Primary Phone *

Spouse's Phone

Email *

Employer

Pet's Name *

Species (dog, cat, etc.) *

Breed *

Age/Date of Birth *

Sex *

Male
Neutered Male
Female
Spayed Female

Does your pet have a microchip identification? *

Yes
No

What is the microchip number?

Pet's Name (2nd Pet)

Species (dog, cat, etc.) (2nd Pet)

Breed (2nd Pet)

Age/Date of Birth (2nd Pet)

Sex (2nd Pet)

Male
Neutered Male
Female
Spayed Female

Does your pet have a microchip identification? (2nd Pet)

Yes
No

What is the microchip number? (2nd Pet)

Has your pet had any previous health problems? *

How did you learn about our clinic? *

I hereby authorize the veterinarians at Park City Animal Clinic to examine, prescribe for or treat the animal described above. I assume full responsibility for all charges incurred in the care of my pet. I understand that the payment is due in full at time of service. A deposit may be required for major medical and surgical procedures.

In the event there is an open balance on my account, a financial arrangement must be made and any balance may be subject to a monthly billing and a financing fee equal to 1.5% of the unpaid balance.

Owner's Signature *

Clear Signature

Date *

New Client FormPark City Animal Clinic

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Location

Contact Information

Hours