New Client Form Bismarck Animal Clinic & Hospital Welcome to our hospital! Thank you for giving us the opportunity to care for your pet. Please complete the following: Pet Owner - Last Name: First Name: Spouse/Other: Primary Phone Number: Secondary Phone Number: Work Phone Number: Spouse/Other Phone Number: Email: Address: City: State: ZIP: Pet's Name Microchip #: Species Breed: Sex: ---FemaleMale Spayed/Neutered? ---YesNo Age/DOB: Color(s)/Markings: Do you know of any previous medical problems? Vaccination history: Name of previous clinic/veterinarian: If we are not your primary veterinarian, may we contact them if needed? ---YesNo Would you like the above clinic to receive information regarding your pet’s visit today: ---YesNo How did you become aware of our hospital? ---InternetPersonal RecommendationPhone BookDakota Country MagazineOther If personal recommendation, whom may we thank? Why did you choose our clinic: Professional fees are due at the time services are rendered. We will gladly prepare a written estimate for any service provided. Please indicate your choice of payment: ---Cash or Personal CheckVisa, MasterCard, Discover, or American Express.Care Credit® Monthly Payment Plan (Ask for further details) To prevent the spread of infectious diseases and parasites, hospitalized patients must be current on all vaccines and free of parasites. I authorize the doctor to provide vaccines and parasite control as needed for my pet. By signing below, I agree to pay at the time of service. Name: Bismarck Animal Clinic Bismarck Animal Clinic1414 E Calgary AveBismarck ND 58501