New Patient Form in Reading, MA | Reading Animal Clinic

Owner's Name*

First Last

Email*

Address*

Street Address Address Line 2 City State ZIP Code

Phone*

Phone Type*

Cell
Home

Spouse/other Name*

Spouse/other Phone*

Preferred contact method*

Phone
Text
Email

Pet's Name*

Pet Date Of Birth

Species*

Dog
Cat

Sex*

Male
Female
Male (Neutered
Female (Spayed)

Breed

Color

Allergies or previous illness?

Does your pet have insurance?*

Yes
No

Carrier*

How did you hear about us?*

Media release - I grant to Reading Animal Clinic the right to take photographs of me and/or my pet, and to use and publish the same in print and/or electronically on social media, as publicity or as web content.*

I authorize RAC to take and use photos
I DO NOT authorize RAC to take and use photos

I assume responsibility for all charges incurred in the care of this animal. I understand that payment is due as services are rendered and that a deposit may be required for hospitalization or surgical treatment. I also understand that medication cannot be dispensed without payment. We will gladly prepare you a written estimate upon request.

Signature*

Please type your name

Date*

New Patient Form

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