New Client Form

New Client Form

Client/Patient Information

First Name

Last Name

Preferred Pronouns

He/Him

She/Her

They/Them

Prefer not to answer

Spouse/Sig. Other First Name

Spouse/Sig. Other Last Name

Home Address

City

State

Zip Code

Primary Phone

Secondary Phone

Your Date of Birth

Employer Name

Employer Address

City

State

Zip Code

Pet Information 1

Name

Breed

Color(s)

Birthdate/Age

Sex

Spayed/Neutered?

Microchipped?

Pet Information 2

Name

Breed

Color(s)

Birthdate/Age

Sex

Spayed/Neutered?

Microchipped?

...am the:

...of the above-described animal(s) and have the authority to execute consent of veterinary treatment and services.

As the owner/agent, I authorize (someone other than myself)

...to make financial and medical decisions (including euthanasia) concerning the treatment of my pet.

Authorized person's phone number

Signature of owner or agent

Sign Here

Payment for all services is due at time services are rendered.

At your request we will gladly discuss the cost of services and/or prepare a written estimate of costs for recommended procedures. A deposit for services is required for pets admitted to the hospital. We accept cash, personal checks, and all major credit cards (Visa, Mastercard, Discover, and American Express). There is a $27 fee for returned checks.

Cheat Lake Animal Hospital

286 Fairchance Road, Morgantown, WV 26508 · Phone: (304) 594-1124 · Fax: (304) 594-1911

Client/Patient Information

Pet Information 1

Pet Information 2

Payment for all services is due at time services are rendered.

Clinic Hours

Proud Sponsor of

and

Our Mission