Clearlake Veterinary Clinic

3424 Emerson Street
Clearlake, CA 95422
(707) 994-9100

Hours: Monday - Friday 8:00am - 6:00pm, Saturday 8:00am - 4:00pm

New Client Check In

If you would like to make an appointment, you can assist us to expedite your check in by submitting this form.

Thank you for your cooporation in letting us assist you.

Form - New Client

Name & Email (required)
First Name (required)
Last Name (required)
CDL# (required)

E-Mail Address (required) :
Spouse's Name
First Name
Last Name
Street Address (required)
Street Address (required)
City (required)
State/Province (required)
Zip/Postal Code (required)
,
Mailing Address (if different from street address)
Street Address
City
State/Province
Zip/Postal Code
,
Daytime Phone (required)
Phone TypePhone Number (required)
Alternate/Evening Phone (required)
Phone TypePhone Number (required)
List alternate/emergency person who can authorize treatment for your pet.
Emergency Contact
First Name
Last Name
Emergency Contact
Phone TypePhone Number
Pet Information:
Pet's Name (required)

Age: DOB (required)

Type of Pet (required) :
Breed:

Sex: (required)
Male
Female

Neutered/Spayed
Neutered
Spayed

Are your pets vaccines current?
Pet Medical Records:
Do you have pets medical records? If 'Yes', please bring them to your appointment.
Medical records at another veterinary Practice?
Yes
No

Name of Former Veterinary Practice

Phone Number of Former Veterinary Practice
Phone TypePhone Number
May we request a transfer of records?
Yes
No

Appointment Information:
Would you like us to call you for your appointment
Reasons or conditions that prompted your visit?

Special requests or conditions?

Additional Pets Information:
Please list any additional pets here. Include description & DOB for each pet listed.

Financial Statement:
Please Read
Payment is due in full at the time of service. An estimate will be presented to you for anything other than a routine visit (well pet exam & vaccines) Payment plans are to be determined prior to treatment and on an individual basis, the terms of which will be set by Clearlake Veteriniary Clinic. All unpaid balances are subject to a monthly billing fee anda 1.5% (18%APR) interest rate. All unpaid balances are subject to collection efforts. The doctor / patient / client relationship will be terminated if there is a default on payment.
I have read this statement and -
I Agree
I Disagree


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