I am a:

New Client - New Patient
Current Client - New Patient
Current Client - Yearly update

Your Name *

First

Last

Your Phone *

Cell Phone

Work Phone

Your Email *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Occupation

Co-owner Name

First

Last

Co-owner Cell Phone

Co-owner Work Phone

Co-owner Email

Co-owner Address

Address Line 1

Address Line 2

City

State

Zip Code

Patient Information

Pet's Name *

Species *

Breed *

Color

Age/Date of Birth *

Sex (male, female)? *

Male
Female

Spayed or Neutered? *

Yes
No
Don't know

Do you have a second pet? *

Yes
No

Pet's Name *

Species *

Breed *

Color

Age/Date of Birth *

Sex (male, female)? *

Male
Female

Spayed or Neutered? *

Yes
No
Don't know

Do you have a third pet? *

Yes
No

Pet's Name *

Species *

Breed *

Color

Age/Date of Birth *

Sex (male, female)? *

Male
Female

Spayed or Neutered? *

Yes
No
Don't know

Do you have a fourth pet? *

Yes
No

Pet's Name *

Species *

Breed *

Color

Age/Date of Birth *

Sex (male, female)? *

Male
Female

Spayed or Neutered? *

Yes
No
Don't know

Do you have a fifth pet? *

Yes
No

Pet's Name *

Species *

Breed *

Color

Age/Date of Birth *

Sex (male, female)? *

Male
Female

Spayed or Neutered? *

Yes
No
Don't know

Emergency Contact (Not Living with you)

Emergency Phone

All fees for professional services or products are due in full at the time of discharge.

We accept Cash, MasterCard, Visa, Discover, and CareCredit or a check along with complete identification. Picture identification is required for all credit cards, debit cards, and checks. There is a $50.00 service fee for all returned checks. In the event of any legal action, I (client) agree to pay all reasonable court costs, deposition fees, and attorney fees.

I (owner) hereby consent and authorize the veterinarian and/or staff to administer any medication, tests, anesthetics, or surgical procedures that the veterinarians deems necessary for the health, safety, or well being of my pet(s) once it has been explained to me. I understand that no guarantee of successful treatment can be made. I further understand that Elko Veterinary Clinic is not a 24-hour facility and my pet may be left unattended.

By law, NAC 638.052 Retaining possession of animals. NRS 638.070, a veterinarian may retain possession of an animal until all money owed to the veterinarian for the care of the animal is paid. If the veterinarian retains possession of the animal, he or she shall continue to care for it in a humane manner. Each day that the pet is here we will charge for the care of the pet according to our standard fee schedule.

Signature Owner 1 *

Clear Signature

Sign above

Signature Owner 2

Clear Signature

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I give Elko Veterinary Clinic permission to post my pet’s picture on their web site or social media.
I do not give Elko Veterinary Clinic permission to post my pet’s picture on their web site or social media.

All Information Remains Confidential

Signature Owner *

Clear Signature

Online Forms

New Client Form

New Client Form

Patient Information

All fees for professional services or products are due in full at the time of discharge.

All Information Remains Confidential

Online Pharmacy

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Receive Automatic Reminders

Request Appointments 24/7

Your Pet's Organizer App

Save Notes, Pics & Much More

Questions?

Address

Contact

Hours

Contact Us

Online Forms

New Client Form

New Client Form

Patient Information

All fees for professional services or products are due in full at the time of discharge.

***All Information Remains Confidential***

All Information Remains Confidential