New Client Form Owner's Name(Required) First Last Spouse/Co-Owner's Name First Last Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Primary Phone(Required)Secondary PhoneSpouse/Co-Owner's PhoneEmail(Required) Are you over the age of 65?(Required) Yes No Please upload a copy of your identification(Required)Max. file size: 256 MB.Are you in the military?(Required) Yes No Please upload a photo for proof of service(Required)Max. file size: 256 MB.Pet's Name(Required) Species(Required) Dog Cat Breed(Required) Color(Required) Age/Date of Birth(Required) Sex(Required) Male Male (neutered) Female Female (spayed) Is your pet microchipped?(Required) Yes No Add a second pet?(Required) Yes No HiddenSecond PetPet's Name(Required) Species(Required) Dog Cat Breed(Required) Color(Required) Age/Date of Birth(Required) Sex(Required) Male Male (neutered) Female Female (spayed) Is your pet microchipped?(Required) Yes No HiddenSection BreakName of Previous Clinic Previous Clinic Phone NumberMay we request medical records? Yes No Any previous illnesses or surgeries?(Required) Yes No If yes, please describe(Required)Is your pet on any special diets or medications?(Required) Yes No If yes, please list the medication name and dosage and/or special diet(Required)Add a second pet?(Required) Yes No HiddenSecond PetPet's Name(Required) Species(Required) Dog Cat Breed(Required) Color(Required) Age/Date of Birth(Required) Sex(Required) Male Male (neutered) Female Female (spayed) Is your pet microchipped?(Required) Yes No HiddenSection BreakI, the undersigned owner, do hereby authorize Blue Diamond Animal Hospital veterinarians to examine my pet and administer treatment for my pet’s condition.(Required) I authorize Blue Diamond Animal Hospital staff Veterinary Graduates Awaiting Licensure (VGAL). While they possess the necessary skills and knowledge, it is essential to acknowledge that their licensure is pending. The well being of the animal remains the primary concern. I'm aware of this arrangement and provide consent to proceed.(Required) I have read and understand I understand that charges will be paid in full at the time of release, and a deposit may be required for certain surgical treatments or other procedures. We accept Visa, MasterCard, Discover, and Cash. We apologize for the inconvenience, but we DO NOT accept American Express, Care Credit, or checks. I understand that should my account become delinquent; I will be responsible for any and all billing and accrued interest charges from the delinquency.(Required) I have read the above-written payment disclosure and accept full responsibility for all costs incurred. I understand that as a condition of treatment by Blue Diamond Animal Hospital, any financial arrangements must be made in advance. In the event that this account should go unpaid, I understand that I will be subject to the cost of collections, including attorney fees and/or collection agency fees By clicking 'I agree', I acknowledge that I am 18 years of age or older and am fully responsible for all charges(Required) I agree Do you give Blue Diamond Animal Hospital permission to take photographs and videos of me and my pet for the purpose of posting on Blue Diamond Animal Hospital’s Facebook, YouTube, Twitter ,Instagram and clinic website?(Required) Yes No Digital Signature(Required) Date(Required) MM slash DD slash YYYY ID/Drivers License(Required)Max. file size: 256 MB.CAPTCHAPhoneThis field is for validation purposes and should be left unchanged.
