Happy Woman With Jack Russell Terrier On Laptop
Happy Woman With Jack Russell Terrier On Laptop

New Client Form

To make your first visit with us as smooth as possible, we ask all new clients to complete our New Client Form before scheduling an appointment. This helps us gather important information about you and your pet, so we can focus on providing exceptional care when you arrive.

Once you’ve filled out the form, we’ll be in touch to confirm your appointment. If you have any questions or prefer to schedule an appointment over the phone, feel free to call us at (937) 773-8060.

New Client Form
Do you have pet health insurance for your pet?
Primary Owner Name
Primary Owner Name
First
Last
Spouse Name
Spouse Name
First
Last
Address
Address
City
State/Province
Zip/Postal
How did you select our hospital?

Payment is due at the time services are provided. For your convenience we accept Cash, Check,
Mastercard, Visa, American Express, and Care Credit.

Do you plan to pay by check?

We offer convenient phone and online prescription refills that can be delivered directly to your home. If
you are interested, please let the receptionist know so we can enter your billing information.

Pet Information

Species
May we contact your previous vet for your pet’s complete medical records?
Is your pet currently on a Heartworm and/or Flea Preventative?
Are there any children in this household?
Does anyone in this household have a compromised immune system?
Are there any other pets in this household?