New Client Information

CLIENT INFORMATION

Your Name*

First MI Last

Your DOB*

MM

DD

YYYY

Spouse's Name

First

Spouse's DOB

MM

DD

YYYY

Referred By

Address*

Street Address Address Line 2 City State ZIP Code

Home Phone

Cell Phone*

Employer

Work Phone*

Driver's License #*

Email*

PET INFORMATION

Name*

Breed*

Color*

Age/DOB*

Previous Vet*

*

Canine
Feline

*

Female
Male

*

Spayed
Neutered

Add Another Pet

I have another pet to add

PET INFORMATION

Name*

Breed*

Color*

Age/DOB*

Previous Vet*

*

Canine
Feline

*

Female
Male

*

Spayed
Neutered

Add Another Pet

I have another pet to add

PET INFORMATION

Name*

Breed*

Color*

Age/DOB*

Previous Vet*

*

Canine
Feline

*

Spayed
Neutered

*

Female
Male

Payment is expected in full at the time of service. Cash accounts enable us to operate more economically, thus reducing your cost of treatment. A deposit will be required when emergency services or extensive medical treatments are performed. A 1.5% service fee will be charged on all unpaid monthly balances.

Photos may be taken of your pet for identification purposes and kept on record for reference. Often, we need reference photos and we prefer to draw from our patient base. These photos may be used on our social media platforms to depict a certain breed or just for a fun reference. We will never release these photos for use outside of our practice. The following will grant us permission to photograph your pet(s) without obligation of financial reimbursement.*

Yes. I grant to Cole Veterinary Hospital, its representatives and employees the right to take photographs of my pet(s) in connection with the above- identified subject, I authorize Cole Veterinary Hospital, its assigns and transferees to copyright, use and publish the same in print and/or electronically, I agree that Cole Veterinary Hospital may use such photographs of my pet(s) without my name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising and web content.
No. I decline to have Cole Veterinary Hospital use or publish photographs of my pet(s) for any reason.

Contact Us

World Rabies Day – September 28th