New Client Form New Client Form Owner Information Name * Name First Name First Name Last Name Last Name Email * Phone * Would you like to opt in to receive text messages from Case Veterinary Hospital? * Yes No Are you in the military? * Yes No Address * Address Address Address City City State/Province State/Province Zip/Postal Zip/Postal Country AfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCôte d'IvoireCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCroatiaCubaCuracaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSaint BarthelemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Who else is authorized to make decisions about your pet's healthcare? * Their Phone Number: * How did you find out about our hospital? If you were referred by someone, who should we thank? Pet Information Pet's Name * Species * Cat Dog Other Breed * Color * Age/Date of Birth * Sex * Male Female Unknown Does your pet have a microchip identification? * Yes No Add Another Pet? * Yes No Pet Information Pet's Name * Species * Cat Dog Other Breed * Color * Age/Date of Birth * Sex * Male Female Unknown Does your pet have a microchip identification? * Yes No To help us make your pet’s visit as low-stress and comfortable as possible, please answer the following: Has your pet ever shown signs of fear, anxiety, or stress during a veterinary visit? Yes No If yes, please describe: Has your pet ever received sedatives or calming medications before a vet or grooming visit? * Yes No If yes, which medication(s) and how did they work? At Case, we have several team members trained in low-stress handling techniques. If you're interested, we can customize your pet's visit using these methods. This approach may involve more time, acclimation sessions, or multiple visits—and may result in additional fees. If that’s not the right fit, we’re also happy to discuss pre-visit calming medications. Please let us know what you’re most comfortable with: Low-stress handling approach Pre-visit calming medications Not sure—please discuss options with me Do you have pet insurance? Yes No If yes, what company is the policy with? Please upload any copies of your pet's records here, if possible. Drop a file here or click to upload Choose File Maximum file size: 52.43MB Payment is due in full at the time that services are performed. If being admitted into the hospital, we cannot begin the care of your pet until you have confirmed your desire to do so by 1) signing the client consent & estimate form and 2) leaving an initial deposit of 50% of the upper end of the estimate. This is the only way that we have of knowing for certain that you want us to proceed with the care of your Pet. We accept Cash, Visa, MasterCard, Discover, CareCredit, and Scratchpay payments. We neither extend credit nor bill for services. Any balance brought forward is subject to a 1.5% finance charge. All open invoices are sent to collections after 45 days unless prior arrangements are made. * I have read and accept the financial policy. I give you permission to medically treat my pet. I consent to have my pet’s picture used by Case Veterinary Hospital, and I understand the following: My pet’s picture may be used on Case Veterinary Hospital’s website, Facebook, Instagram or any media site that suits the Hospital. I can withdraw my consent at any time I will receive no compensation for my consent I understand pictures may be copied and used by Case Veterinary Hospital without further permission. * Yes, I consent No, I do not consent I confirm that all information submitted on this form is correct to the best of my knowledge. * signature keyboard Clear Captcha Submit If you are human, leave this field blank.
