New Client Forms | Fairlea Animal Hospital in Lewisburg, WV

Welcome, New Clients!

We are pleased to welcome you to our practice. Please take a few minutes to fill out this form as completely as you can.

If you have questions, we will be glad to help you. We look forward to working with you in maintaining your pet’s health.

Owner's Name(Required)

Social Security #

Driver’s License

Address

Street Address City State ZIP Code

Contact Details

Home Phone*(Required)

Cellular Phone

Email(Required)

Employer

Business Phone

Spouse or Co-Owner Name

Spouse or Co-Owner Phone

Whom can we thank for telling you about our practice? Please give a name if applicable

Authorization Disclaimer

We will gladly prepare a written estimate of service fees if you desire. All professional fees are due at the time services are rendered.

There will be a service charge for any returned check. In the event that my account is submitted to a collection agency, I understand that I will be responsible to pay a $35 collection fee.

I also agree to pay all costs of collection, including reasonable interest fees, reasonable attorney’s fees, and reasonable collection agency fees.

To prevent the spread of infectious diseases, all hospitalized patients must be current on all vaccines and free from internal and external parasites.

The signature below authorizes this level of preventative care and the appropriate charges will be assessed in the discharge invoice.

Authorization Signature(Required)

Photo/Video Disclaimer

Please initial the fields below.

I hereby grant permission to Fairlea Animal Hospital and it’s employees or representatives, to take and use photographs, digital images and/or videos of me/my pet(s) for use in promotional or educational materials in electronic or printed publications or presentations, on the Fairlea Animal Hospital website and/or on the Fairlea Animal Hospital facebook page.

Initial Here

I authorize the use of these images indefinitely without compensation to me/my pet. All prints, digital images and videos shall be the property of Fairlea Animal Hospital.

Initial Here

Name of Client Responsible for Pet(s)(Required)

CAPTCHA

Name

This field is for validation purposes and should be left unchanged.