Cloverleaf Animal Clinic

749 N. White Station
Memphis, TN 38122

(901)682-5681

www.cloverleafac.com

 

New Client Form

 

Decorative Bone Divider

   

New Client Information Form

Do you have a new patient appointment already scheduled?
If so, please enter the date and time below. Note: entering a date and time below will not schedule an appointment for you. You must call our office at 901-682-5681 to schedule.
Appointment :
Name (required)
First Name (required)
Last Name (required)
Spouse
First Name
Last Name
Address (required)
Street Address (required)
City (required)
,		State / Province (required)
Zip / Postal Code (required)
E-Mail Address (required) :
Phone (required)
Phone TypePhone Number (required)
Phone
Phone TypePhone Number
Phone
Phone TypePhone Number
Spouse Phone
Phone TypePhone Number
Employer (required)

Referral

Preferred contact method (required)
Home
Cell
Email
May we text you for reminder purposes? (required)

Yes
No


PET INFORMATION
WHERE were your pets last vaccinated? (required)

Pet's name: (required)

Pet's DOB/Age: (required)

Breed: (required)

Color: (required)

Sex: (required)

Male
Female


Neutered? (required)

Yes
No
Unknown


Is your pet microchipped? (required)

Yes
No
Unknown


I understand that payment is REQUIRED at the time services are rendered. We accept cash, VISA, Mastercard, Discover, and Care Credit. We do not accept checks.
I authorize Doctors to run laboratory test, take radiographs, and/or perform surgery in attempt to arrive at a proper diagnoses and to affect the best possible treatment.
DUE TO STATE LAW AND INSURANCE REQUIREMENTS, ALL DOGS &CATS MUST BE CURRENT ON RABIES VACCINATION. Vaccination can and will be updated at the time of your appointment if not current.
I agree to reimburse us the fees of any collection agency, which may be based on a percentage at maximum of 32% of the debt, and all costs, expenses, including reasonable attorney's fees, we incur in such collection efforts.
In the event payment is not made in 30 days, I further agree to pay 1.5% per month on the unpaid balance with minimum of $3.00 per month billing charge.
I am at least 18 years of age.
Date (required) :
By checking yes and submitting this form, I agree that all information above is correct to the best of my abilities. I further agree to all terms and conditions listed on this form. (required)

Yes
No


Photo I.D.
We will require photo identification at your first appointment. For example: driver's license, passport, etc.

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