Which location do you prefer? *

Which doctor do you prefer? *

Name *

First

Last

Email *

Primary Phone *

Secondary Phone

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Spouse/Co-Owner Name

First

Last

Spouse/Co-Owner Phone

How do you wish to receive reminder notifications? *

Mail
Email

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

Which pet insurance do you use? *

If Other, please specify. *

Do you have a preferred boarding/grooming/enrichment facility? *

If Other, please specify.

Pet's Name *

Breed *

Age/Date of Birth *

Color *

Sex *

Male
Neutered Male
Female
Spayed Female

Would you like to add another pet? *

Yes
No

Pet's Name *

Breed *

Age/Date of Birth *

Color *

Sex *

Male
Neutered Male
Female
Spayed Female

Does Your Pet Have Previous History at Another Veterinary Clinic? *

Yes; please contact my previous veterinarian.
Yes; I prefer to contact my previous veterinary clinic to obtain my pet's medical records.
No; I would like to contact my previous veterinary clinic to obtain my pet's medical records.

Previous Veterinary Clinic *

You may choose to pay by cash or credit/debit card (Visa, Mastercard, American Express, or Discover). We also accept payments through CareCredit. You can apply for a CareCredit account at www.carecredit.com or by calling 1-800-365-8295. You can also apply here at our office. *

I have read and understand.

We accept checks from established clients only and we reserve the right to refuse a check at any time for any reason. Checks not payable by the bank are forwarded to CheckNet in Wichita Falls, TX. A fee of $30 plus applicable taxes is charged by CheckNet for each returned check. *

I have read and understand.

In the event that you have a balance on your account, you will receive a monthly statement. We reserve the right to impose a $5 billing fee on an account each time a statement is mailed. The full balance on your statement is due and payable when the statement is issued and is past due if not paid by the due date displayed on the statement. *

I have read and understand.

If your account becomes past due, we will take necessary steps to collect this debt. If we have to refer your account to a collections agency, you agree to pay all of the collection costs which are incurred. If we have to refer collection of the balance to a lawyer, you agree to pay all lawyers' fees which we incur plus all court costs. In case of suit, you agree the venue shall be in Randall County, TX. *

I have read and understand.

Due to Texas state law, all pharmaceutical and nutraceutical sales are final. *

I have read and understand.

The veterinarians at Swann Animal Clinic may use some medications in an extra-label manner in accordance with The Animal Medicinal Drug Use Clarification Act of 1994. Examples of extra-label drug use include: use in another species, use for a different indication, use at a different dose or frequency, and use via a different route of administration. If you have any questions regarding extra-label drug use, please consult with your veterinarian. *

I have read and understand.

By checking the box below marked "Accept", you are agreeing to all the polices above and that you are responsible for all fees incurred. This includes any medication and diagnostic procedures. The responsibility continues in the event that the patient fails to recover or is euthanized. I hereby authorize the veterinarian to examine, prescribe for, or treat the above pet(s). I assume responsibility for all charges incurred in the care of this animal. I also understand that charges will be paid at the time of release and that a deposit may be required for surgical or extensive medical treatment. *

Accept

Signature *

New Client Form

Caring for the pets of Amarillo, TX

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SAC at 45th

SAC at Hillside

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