New Client Form - Chenango Animal Hospital | Veterinarian in Binghamton, NY

Client Information Form

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About You

Your Name(Required)

First Last

Co-Owner Name

First Last

Pet's Name(Required)

Date of Birth(Required)

Species(Required)

Breed(Required)

Color(Required)

Sex(Required)

Your Address(Required)

Street Address Address Line 2 City ZIP Code

How Can We Reach You?

Preferred Method of Contact(Required)

E-mail and texting are both used for sending wellness and appointment reminders. Additionally, e-mail is used for sending estimates and invoices.

Your Email Address(Required)

Co-Owner Email Address

Primary Phone Number(Required)

Phone Type(Required)

Co-Owner Phone Number

Phone Type

Payment Agreement

Estimates for services are provided upon request. If you have any questions regarding what fees may be applied during your pet's visit, we encourage you to ask before services are provided. Payment is due at the time services are rendered. We accept Debit/Credit Cards, Care Credit, and Cash. We DO NOT accept personal checks.

Medications-All Sales Final

ALL MEDICATION SALES ARE FINAL. By law, NYS Article 137, Pharmacy Law, we cannot accept returns of prescription products for reuse or resale. Once products leave the building, we cannot control how they are handled for stored, which can affect their efficacy and make them unsafe to be dispensed for another patient. In addition to prescription medications, all supplements/nutraceuticals, as well as flea and tick products are also final sale.

Rabies Status

Rabies vaccination is required by law in New York State for all dogs, cats, and ferrets; Public Health Article 21 Title 4. For our staff's protection, ALL PATIENTS THAT WE HANDLE MUST BE VACCATINATED AGAINST RABIES. It is necessary for us to have current proof of rabies in your pet's file. Only pets with a medical condition (diagnosed by a veterinarian) in which vaccination is contraindicated are exempt from this policy. If you choose to withhold rabies vaccination from your pet, a RABIES STATUS UNKNOWN FEE will be applied to your invoice each time we must handle your unvaccinated pet.

Cell Phone Use

To better serve all clients, we kindly request that you refrain from cell phone use for the duration of your pet's appointment while staff are present in the exam room.

Client Signature

Date