About You

Client Name *

First

Last

Date of Birth

Spouse Name

Email *

Home Phone *

Cell Phone *

Spouse Phone

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Employer Name *

Work Phone

Preferred Method of Contact: (Please circle one) *

Home
Cell
Work

Preferred Method of Contact for Reminders: (Please circle one) *

Call
E-mail
Text

How were you referred to our office? *

About Your Pet(s)

Pet's Name *

Sex *

Male
Neutered Male
Female
Spayed Female

Age/Date of Birth *

Species (dog, cat, etc.) *

Breed *

Color *

Date of Last Vaccines

Location of Last Vaccines

Has your pet has been to another vet?

If so, where?

Does your pet have a microchip identification? *

Yes
No

Do you have a second pet? *

Yes
No

Pet's Name *

Sex *

Male
Neutered Male
Female
Spayed Female

Age/Date of Birth *

Species (dog, cat, etc.) *

Breed *

Color: *

Date of Last Vaccines

Location of Last Vaccines

Has your pet has been to another vet?

If so, where?

Do you have a third pet? *

Yes
No

Pet's Name *

Sex *

Male
Neutered Male
Female
Spayed Female

Age/Date of Birth *

Species (dog, cat, etc.) *

Breed *

Color *

Date of Last Vaccines

Location of Last Vaccines

Has your pet has been to another vet?

If so, where?

Payment Policy

Our office does not offer billing. Payment is due on the day of service. We will gladly prepare a written estimate if you desire. Please ask our doctor during your appointment. Occasionally, a deposit may be required for certain procedures. We accept the following forms of payment: cash, personal check, credit/debit, including CareCredit, Visa, Mastercard, Discover, and American Express.

**Please note that when writing a personal check, a copy of a valid driver’s license will be needed for processing. In addition to any fees your bank may charge, there is a $35 fee for a returned check.

Treatment / Payment Authorization

I understand every effort will be made to achieve a successful outcome, and provisions will be made for safe in-hospital care and handling. I certify that I am 18 years of age or older and assume responsibility for all charges incurred. I understand that charges are due at the time services are completed, unless prior arrangements have been made. I agree that, should my account become delinquent, I will be responsible for all collection costs, including but not limited to outstanding balance, interest, attorney fees, court costs, and collection agency fees.

I hereby authorize Iberia Animal Clinic to treat my pet(s) and furthermore understand that unforeseeable adverse reactions to treatments are always possible, and authorize treatment necessary should any reactions occur.

Signature of Owner or Authorized Caretaker *

Clear Signature

By signing, you confirm that you have read and agree to the above statements and that all information provided is true and accurate to the best of your knowledge.

NewClient Form

Making Your First Visit Easier

Client & Pet Registration

About You

About Your Pet(s)

Payment Policy

Treatment / Payment Authorization

Have a Question?

Location

Contact Information

Hours

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