New Clients Welcome – Schedule your first appointment and experience the Eastgate Veterinary Clinic difference!

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New Client Form

Welcome to Eastgate Veterinary Clinic!

Thank you for giving us the opportunity to care for your pet. Please help us to meet your needs and the needs of your pet(s) by taking a moment to complete this information sheet.

Client/Patient Information

Primary Owner(Required)

First Name

Last Name

Additional Notes or Preferences

Secondary Owner

First Name

Last Name

Additional Notes or Preferences

Address(Required)

Street Address

Street Address Line 2

City

State / Province / Region

ZIP / Postal Code

Primary Owner's Phone Number(Required)

Secondary Owner's Number

Email(Required)

Preferred method(s) of contact(Required)

Phone

Text

Emergency Contact

First Name

Last Name

Emergency Contact's Phone Number

Pet(s) Information

Pet's Name(Required)

Date

Approximate Age if no Date of Birth Available

Breed(Required)

Sex(Required)

Male

Neutered Male

Female

Neutered Female

Unknown

List any previous Veterinary Clinics that have seen your pet(s).

Add Another Pet?

Yes

Pet's Name(Required)

Date

Approximate Age if no Date of Birth Available

Breed(Required)

Sex(Required)

Male

Neutered Male

Female

Neutered Female

Unknown

List any previous Veterinary Clinics that have seen your pet(s).

Add Another Pet?

Yes

Pet's Name(Required)

Date

Approximate Age if no Date of Birth Available

Breed(Required)

Sex(Required)

Male

Neutered Male

Female

Neutered Female

Unknown

List any previous Veterinary Clinics that have seen your pet(s).

I Authorize Eastgate Veterinary Clinic to Post my Pet's Picture and/or Story on Social Media(Required)

Yes

Payment Information

Please Read and Sign:

Fees for services are due at the time services are rendered.

A deposit may be required for surgical treatment. We will gladly prepare a written treatment plan with estimated costs, if you desire. For your convenience, we accept personal checks, all major credit cards, CareCredit and ScratchPay. Any account with a balance over 30 days will be assessed a finance charge of 1.5% per month with a $5.00 dollar minimum per month charge.

ALL PATIENTS VISITING EASTGATE MUST BE CURRENT ON THEIR RABIES VACCINE AND FREE OF INTERNAL AND EXTERNAL PARASITES. An examination may be necessary to administer a rabies vaccine. I authorize the doctor to provide a rabies vaccination and parasite control with an exam if needed for my pet.

Signature

Today's Date

MM slash DD slash YYYY