New Client Form

Please fill out this form as completely and accurately as possible so we can get to know you and your pet(s) before your visit. Please note: all * fields are required.

Name *

First

Last

Email *

Primary Phone *

I consent to receive SMS text messages from Mellina Animal Hospital. Msg & data rates may apply. Reply STOP to opt-out. *

Yes
No

Secondary Phone

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Who else is authorized to make decisions about your pet's healthcare? *

First

Last

Phone

How did you find out about our hospital? If you were referred by someone, who should we thank? *

Pet's Name *

Species (dog, cat, etc.) *

Breed *

Age/Date of Birth *

Sex *

Male
Neutered Male
Female
Spayed Female

Does your pet have a microchip identification? *

Yes
No

Payment is due in full at the time that services are performed. If being admitted into the hospital, we cannot begin the care of your pet until you have confirmed your desire to do so by 1) signing the client consent & estimate form and 2) leaving an initial deposit of 50% of the upper end of the estimate. This is the only way we have to know for certain that you want us to proceed with your pet's care. We accept Cash, Visa, MasterCard, Discover, and CareCredit payments. We neither extend credit nor bill for services. All open invoices are sent to collections after 45 days unless prior arrangements are made. *

I have read and accept the financial policy.

Name

New Client Form

New Client Form

Please fill out this form as completely and accurately as possible so we can get to know you and your pet(s) before your visit. Please note: all * fields are required.

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