Grass Lake Animal Hospital

1011 Norvell Rd.
Grass Lake, MI 49240

(517)522-6789

grasslakeanimalhospital.com


If you prefer to download a copy of this form, you may do so here.


New Patient Visit Form

Name (required)
First Name (required)
Last Name (required)
Address (required)
Street Address (required)
City (required)
,
State / Province (required)
Zip / Postal Code (required)
Phone (required)
Phone TypePhone Number (required)
E-Mail Address :
Driver's License Number

For your convenience, please provide your driver's license number. This will alleviate future requests each time you pay by check. We also use it to positively identify you as your pet's owner, when discussing sensitive information by phone. The DEA also requires us to have this number for certain pet prescriptions. This information will be kept confidential.
Driver's License Number (#State).

Is there another adult who is authorized to make pet care decisions?
Name:

Relationship:

Address:

Phone:

Pet Information
Pet Name: (required)

Species: Dog/Cat/Other (required)

Breed (required)

Sex: Male/Female/Unknown, Intact or Neutered/Spayed (required)

Color/Markings (required)

Birthday/Age (required)

Other: allergies, anxieties, previous surgeries or serious illness (required)

Previous veterinarian, do you wish us to request your pet's records? (required)

How did you hear of us? (required) :
If recommended by someone, who may we thank? If you answered other, where did you hear about us?

Payment Information

Please check the website for current coupons. Payment is due at the time of services. We accept cash, Visa, MasterCard, Discover and ATM or debit cards, and checks. We also accept CareCredit which can provide interest free repayment plans to qualified persons. Most applications receive same day approval.
Financial Responsibility

This information is accurate and true to the best of my knowledge. I understand that I am responsible to pay for services rendered, including reasonable attorney's fees and costs of collection in the event of default. I further understand that if my account is delinquents, interest will accrue from the due date at 18% annually, or the maximum rate allowed by law.
Photos

I agree that photos of my pet or their procedure may be used anonymously, for Facebook, other social media or educational purposes.

By selecting the "Submit the Form" button, you are signing this agreement electronically. You agree your electronic signature is the legal equivalent of your manual signature on this agreement. By selecting "Submit the Form" you consent to be legally bound by this agreement's terms and conditions. By selecting "Submit the Form", you vouch for the information provided in this agreement as accurate and that you are the legal owner of this animal.

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