Silver Maple Veterinary Clinic, Inc.
14993 Kutztown Road, Kutztown PA 19530
610-683-7988
New Client Form (Page 1 of 3) [1] [2] [3]

Date
Owner
Spouse/Other
Address City State
Zip
Home # Work # Cell #
E-mail Address

Employment Information:
Employer's Name
Address City State
Zip
Spouse/Other's Employer's Name
Address City State
Zip

When is the best time to call about your pet?
Time Phone #
In case if emergency, please call:
Name Phone #

We will gladly prepare an estimate for you upon request. PROFESSIONAL FEES ARE DUE AT THE TIME SERVICES ARE RENDERED. If you pay by check or credit card please complete the following. WE CANNOT ACCEPT CHECKS WITHOUT DRIVER’S LICENSE NUMBER ON FILE.
If Payment is by Credit Card:
Credit Card Acct. # Security Code # Exp.
If Payment is by Check:
Bank Driver's LIcense # State

How did you first hear of our hospital?
Individual / Someone we can thank?
Referral
Hospital Sign Yellow Pages Website Other

To prevent the spread of infectious diseases and parasites, hospitalized and boarded animals must be current on all vaccines and free of internal and external parasites. I understand and authorize the doctor to provide vaccines and parasite control as needed for my hospitalized or boarded pet.
You will be asked to sign and date the form when you arrive at the clinic.
Signature ________________________________________________ Date ________________________

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