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Last *

First *

Spouse

Mailing Address *

Address Line 1

Address Line 2

City

State

Zip Code

Cell Contact *

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Alternate Contact

Spouse

Work Contact *

Pet Information

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Name *

Species *

Breed *

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Sex *

Male
Female
Male Neutered
Female Spayed

Color *

Date of Birth / Age *

Previous Vet Clinic

Do you have a second animal? *

Yes
No

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Previous Vet Clinic

Do we have permission to use your pet’s picture(s) for learning and/or Social Media purposes? *

Yes
No

Do you have Pet Insurance for any of the pets listed? *

Yes
No

If yes, please list: *

How did you choose Gaines + Shoal Animal Clinic?

If you were referred by someone, please list them here:

If you were referred by an employee, please list them here:

If you chose internet site, which one?

If you chose other, please explain:

Professional fees are to be paid at the time services are rendered. We do not carry open accounts and hope that these alternatives are convenient to you: Cash, Mastercard, VISA, American Express, Discover and Care Credit.

We can provide you with a written estimate of fees for any case where in-hospital treatment, emergency care, surgery or hospitalization occurs. A deposit prior to treatment may be required.

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Owner's Signature (18+ years of age) *

Printed Name *

Date *

Financial Policy

Thank you for choosing Gaines + Shoal Animal Clinic. Our primary mission is to deliver the best and most comprehensive veterinary care available for your pet. An important part of the mission is making the cost of optimal care as easy and manageable for our clients as possible by offering several payment options. Gaines + Shoal Animal Clinic requires payment in full at the end of your pet’s examination and/or at the time of discharge. Gaines + Shoal Animal Clinic does not offer any type of payment plan other than Care Credit ©

Payment Options

Allows you to begin treatment today and pay over time
Can be used repeatedly without having to reapply

For clients with Pet Insurance, we are happy to provide the necessary documentation to submit a claim to your insurance carrier.

For some treatment or hospitalization, a deposit may be required.

Additional Policy Information

Gaines + Shoal Animal Clinic charges for a returned check.

By signing below, you agree to the foregoing terms of payment.
Anyone sent in your place is authorized to approve treatment deemed necessary.

If you have any questions, please do not hesitate to ask. We are here to provide the best veterinary care available for your pet.

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Owner's Signature (18+ years of age) (copy) *

Printed Name (copy) *

Date (copy) *

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New Client Form

Pet Information

Financial Policy

Payment Options

Additional Policy Information

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