Please select your clinic: *

Owner's Name *

First

Last

Spouse

Address *

Address Line 1

Address Line 2

City

State

Zip Code

County of Residence *

Email *

*Required for important reminders for your pet.

Driver's License State and Number

Cell Phone

Work Phone

Additional Phone

How did you hear about Express Vets? *

Who can we thank for referring you?

How did you hear about us?

Patient Name *

Species

Cat
Dog

Spayed/Neutered?

Yes
No

Breed

Color

Age or Date of Birth

Sex

Male
Female

Has pet been vaccinated in the last 12 months?

Yes
No
Unknown

List any past or ongoing medical issues:

Would you like to add information for another pet? *

Yes
No

Patient Name *

Species

Cat
Dog

Spayed/Neutered?

Yes
No

Breed

Color

Age or Date of Birth

Sex

Male
Female

Has pet been vaccinated in the last 12 months?

Yes
No
Unknown

List any past or ongoing medical issues:

Form of Payment *

Credit Card
Check
Cash

Payment is due at the time services are rendered. I understand there will be a service charge of $35.00 on all returned checks. I will be responsible for payment of all charges incurred on behalf of this/these animal(s) and any future animals I bring in for services at Express Vets. A collection fee will be added to the balance of any accounts sent to a collection agency. *

I have read and understand

Responsible Party’s Signature *

Date *

Express Vets wants to make your pet(s) Facebook famous or the next Instagram Influencer. Do we have your consent to share your pet’s image or video footage on our social media sites, website, or marketing material? *

Yes, I authorize the use of video and/or photography
No, I do not authorize the use of video and/or photography

What is your pet’s Instagram username so we can follow him/her?

Express Vets
New Client Form

Use the form below to submit your new client information.

We look forward to meeting you and your pet!

Express Vets New Client Form

Use the form below to submit your new client information.

We look forward to meeting you and your pet!

Express Vets
New Client Form