New Clients Form | Yukon Veterinary Hospital

We Can’t Wait to Meet You and Your Pet!

If you prefer to print out the form and bring it, download it here.

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"*" indicates required fields

Pet Owner Information

Name**

First Middle Initial Last

Spouse Name:

First Middle Initial

Driver's License #

Date of Birth

Social Security #

Address**

Street Address* City* State* Zip Code*

Phone**

Email**

Employer Information

Owner Dept/Title

Owner's Employer Address

Phone

Spouse Dept/Title

Spouse's Employer Address

Phone

Emergency Contact

Name**

Address**

Phone**

Relation**

Pet Information

Pet's Name**

Dog or Cat?**

Breed**

Color**

Date of Birth/Approximate Age**

Gender

Spayed/Neutered?

Are They Microchipped?

On Heartworm Preventative?

On Flea/Tick Preventative?

Microchip #

Have More Pets to Add?*

Second Pet Information

Pet's Name**

Dog or Cat?**

Breed**

Color**

Date of Birth/Approximate Age**

Gender

Spayed/Neutered?

Are They Microchipped?

On Heartworm Preventative?

On Flea/Tick Preventative?

Microchip #

Have a Third Pet to Add?*

Third Pet Information

Pet's Name**

Dog or Cat?**

Breed**

Color**

Date of Birth/Approximate Age**

Gender

Spayed/Neutered?

Are They Microchipped?

On Heartworm Preventative?

On Flea/Tick Preventative?

Microchip #

Thank You for Choosing Us!

How did you hear about our clinic?**

Location

Hospital Sign

Web Search

Personal Recommendation

Other

Whom May We Thank?

Financial Policy

Thank you for choosing YUKON VETERINARY HOSPITAL. Our primary mission is to deliver the best and most comprehensive veterinary care available for your pet.

An important part of the mission is making the cost of optimal care as easy and manageable for our clients as possible by offering several payment options.

You can choose from:

- Cash, Check, Visa®, American Express®, MasterCard® or Discover Card®
- Convenient Monthly Payment Plans* from CareCredit®
- Allow you to begin treatment today and pay CareCredit over time
- Available for any treatment amount
- Can be used repeatedly without having to reapply

We do not offer any in-house payment plans. We charge 1.5% interest on all outstanding balances older than 30 days. If you have an account 90 days past due, YUKON VETERINARY HOSPITAL will relinquish your balance owed to a collection agency.

By signing below, you give permission to YUKON VETERINARY HOSPITAL and its agents to contact you on any phone number/email that has been provided, including cell phone and emergency contacts, for the purpose of collecting a debt.

YUKON VETERINARY HOSPITALequires payment the day services are rendered, or at the time of patient discharge. For clients with pet insurance, we are happy to provide you with the necessary documentation to submit a claim to your insurance carrier.

There is a fee of $27.50 for all returned checks.

If you have any questions, please do not hesitate to ask. We are here to provide the best veterinary care available to your pet.

By signing below, you agree to the aforementioned terms of payment:

Owner's Electronic Signature**

First Name Last Name

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Name

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New Client Form

We Can’t Wait to Meet You and Your Pet!

Pet Owner Information

Employer Information

Emergency Contact

Pet Information

Second Pet Information

Third Pet Information

Thank You for Choosing Us!

Financial Policy