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New Client Form

Once the Client Check-In Form is completed, we will then proceed with contact over the phone to discuss your pet’s history and symptoms as well as going over estimate and payment options. We will do our very best to ensure care is provided in a timely manner while simultaneously minimizing person-to-person contact.

We greatly appreciate your patience as we work to continue to provide top quality care while minimizing the risk of illness to our staff and clients.

Client Check-In Form

All fields marked with * are required.

HAVE YOU BEEN HERE BEFORE WITH THIS OR ANY OTHER PETS?*

Client Information

Name*

Spouse or Roommate

Address*

Primary Phone *

Alternate Phone

Email

Parking Spot #*

Please share this information with us so we can find your car if you are waiting in the parking lot.

Patient Information

Pet’s Name*

Species*

Breed*

Color

Age*

Months or Years?*

Sex*

Spayed/Neutered*

Current on Vaccinations*

Current on Heartworm Prevention*

Pet’s Primary Veterinarian or Clinic*

Pet’s Presenting Problem*

How did you hear about us?*

PAYMENT IN FULL IS DUE AT THE TIME OF SERVICE

Please read carefully; a signature is required before examination or treatment will be given.

All fees are due at the time services are rendered. I further understand that I am responsible for all fees associated with my pet’s treatment.

I certify that I am at least eighteen (18) years of age or older and am the owner or authorized agent for the above listed pet. I hereby consent and authorize Waco Animal Emergency Clinic, and its doctors, employees, and representatives to administer such treatment, diagnostic, surgical and anesthetic procedures as they deem necessary. None of the above will be held liable or responsible in any manner whatever, under any circumstance for the care, treatment or safekeeping of the animal described above, as it is thoroughly understood, I assume all risks.

I hereby certify that I have read and fully understand the above authorization for medical and/or surgical treatment. I also verify that no guarantee or assurance has been made as to the results that may be obtained. Further, I assume financial responsibility for all charges incurred to patient, consent to release of medical information, and authorize direct payment to Waco Animal Emergency Clinic.

On occasion, me or my pet’s likeness may be captured on video, photographs or other media. I hereby authorize and grant to Valley Veterinary Care and its affiliates a perpetual, royalty-free license to publish, distribute, use, broadcast, adapt or otherwise use such media for any commercial or non-commercial purpose. I understand I will not be compensated for any such use nor receive prior notice of any such use. I consent to receiving communications from Waco Animal Emergency Clinic email, phone, and text messages.

OWNER/AGENT*

Smileback$99 none 6:00 pm - 8:00 am 6:00 pm - 8:00 am 6:00 pm - 8:00 am 6:00 pm - 8:00 am 6:00 pm - 8:00 am Open 24 Hours Open 24 Hours https://www.google.com/search?q=Waco+Animal+Emergency+Clinic+map&rlz=1C1CHBF_enPH885PH885&ei=MEOBYIv_KIu0mAX32o6QCw&oq=Waco+Animal+Emergency+Clinic+map&gs_lcp=Cgdnd3Mtd2l6EAMyBQghEKABOgcIABBHELADOgsILhDHARCvARCTAjoJCAAQyQMQFhAeOggIIRAWEB0QHlDOVlj_XGDAXmgBcAJ4AIABlgGIAfgEkgEDMC41mAEAoAEBqgEHZ3dzLXdpesgBCMABAQ&sclient=gws-wiz&ved=0ahUKEwiL1_WbxpHwAhULGqYKHXetA7IQ4dUDCA8&uact=5#lrd=0x864f817a2df46529:0x6b71414a7810e55a,1,,, https://www.facebook.com/wacoanimalemergency/reviews/?ref=page_internal