New Client Form - Aliante Animal Hospital

Please only use this form if directed to by a member of Aliante Animal Hospital’s staff as this form is used to authorize us to examine/treat your pet.

All fees are due at the time the patient is released. If using a credit card, we accept Visa, Mastercard, and Discover. Payments by personal check require your photo ID or a valid Nevada driver’s license. No out-of-state or starter checks are accepted.

* Indicates a required field.

Owner's Information*

Owner's Address*

Apt./Unit Number

City*

State*

Zip Code*

Owner's Phone Number*

Alternate Contact Information
Alternate Contact's Name

Alternate Contact's Phone Number

Alternate Contact's Email

In addition to phone calls and postal mail, we also like to communicate with our clients via e-mail. Please provide us with your e-mail address so we may send you important health information regarding your pet. Be confident that we will keep your e-mail address private, just as we do the rest of your account information.

Owner's Email (recommended)

Pet Information

Pet's Name*

Pet's Species*

Pet's Sex*

Pet's Birthday*

Pet's Breed*

Do you have pet insurance?*
YesNo

2nd Pet Information
Pet's Name

Pet's Species

Pet's Sex

Pet's Birthday

Pet's Breed

Referment
Were you referred to Aliante Animal Hospital by another pet owner?*
YesNo

If yes, please provide their information below:

Authorization
I hereby authorize the veterinarians at Aliante Animal Hospital to examine, prescribe for and treat the above-described pet(s). Any animal admitted or hospitalized shall receive the necessary diagnostic tests and treatment to ensure proper medical care. I agree to pay for all services rendered and medications, goods, and supplies when purchased. I understand that a deposit may be required for surgical or medical treatment. ALL FEES ARE DUE AT THE TIME SERVICES ARE RENDERED.

Financial Policy
By signing below I assume full financial responsibility for any treatment my pet receives. I understand that full payment is due at the time services are rendered. I also understand that a deposit may be required for extensive services.

Owner's Signature*

Today's Date*