New Client Form Step 1 of 333%Owner Name*Co-Owner NameAddress* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email AddressHome NumberWork NumberCell Number*Co-Owner Work NumberCo-Owner Cell NumberName of Previous ClinicPhoneMilitaryYesNoSeniorYesNoRecommended by Whom?Place of Employment First PetSelect One:*DogCatPet InformationNameBreedMicrochip#Date of BirthColorSexSpayed or NeuteredDate of VaccinationsRabiesDA2PParvoBordatella Date of VaccinationsRabiesFELVENT-FVRCP Second PetSelect One:DogCatPet InformationNameBreedMicrochip#Date of BirthColorSexSpayed or NeuteredDate of VaccinationsRabiesDA2PParvoBordatella Date of VaccinationsRabiesFELVENT-FVRCP Third PetSelect One:DogCatPet InformationNameBreedMicrochip#Date of BirthColorSexSpayed or NeuteredDate of VaccinationsRabiesDA2PParvoBordatella Date of VaccinationsRabiesFELVENT-FVRCP Communication PreferencesDo you agree to receive text message communications from us?*YesNoDo you agree to receive email communications from us?*YesNoDo you give permission to use photographs or videos of your pets on social media?*YesNo Return Policy Over the counter, unopened, non-perishable merchandise may be returned within 14 calendar days with an original receipt. Prescription medication is legally prohibited from being resold in the state of Florida. Therefore, all prescription medication is non-refundable.Please Initial to confirm you have read our "Return Policy"*Prescription PolicyWest Villages Animal Clinic has a fully stocked pharmacy, plus several online pharmacies. Our online pharmacies include Pro Plan Vet Direct, Hills to Home and VetSource. The links to these pharmacy options can be found on the upper left corner of our website homepage. All prescriptions purchased from our pharmacies are FULLY manufacturer-warranted and guaranteed. We make every effort to price our prescription products competitively, and often for less after rebates and specials, than many online pharmacies.We are aware of the many options available for pet prescriptions. In the event you wish to purchase from a third-party pharmacy, we ask that you read our pharmacy policy. We will provide a written prescription upon request, provided that we have recently examined your pet, that its required tests are current, and that the particular medication or product requested is appropriate based on the weight and health of the animal. The timeframe of "recent examination" and "current" test is at the doctor's discretion but will never exceed more than one year from your pet's last annual examination and last negative/normal test.The written prescription will be provided directly to you. You may request to pick it up directly from the clinic or ask to have it mailed to your home address. We do not charge a fee for writing prescriptions for our patients. If you would like the written prescription mailed to your home address, there is a $5 shipping & handling fee. Prescriptions will be available for pick-up at our office during regular business hours, within two business days of your request.If you choose to use an internet or outside pharmacy to obtain your pet's medications, you should mail the original written prescription to the pharmacy. We do not respond to fax, email or telephone calls requesting prescription authorizations from any online or outside pharmacies. Special security features of our written prescriptions prevent any attempt to fax, copy or scan them by causing "VOID" to appear across the copied prescription, thus invalidating it. Carefully select your outside pharmacy. Unfortunately, due to unethical practices and consistent medication errors made at several online/outside pharmacies, West Villages Animal Clinic has created this policy. The purpose of this policy is to ensure the health and safety of your pet and thus will not be deviated away from under any circumstances.Please Initial to confirm you have read our "Prescription Policy"*Financial Policy Payment is due at the time services are rendered. An estimate (verbal or written) will be provided prior to service. The bill may be more or less than estimated due to unforeseen factors or changes in the patient’s condition. I agree to pay the final bill, in full, at the time services are rendered. West Villages Animal Clinic does not accept checks. We do accept Cash, Visa, Mastercard, Discover, American Express and Care Credit.I certify that I am the owner and/or agent of the above animal and have the authorization to consent to treatment if and when it is needed.Please Initial to confirm you have read our "Financial Policy"*Date* Date Format: MM slash DD slash YYYY Signature*NameThis field is for validation purposes and should be left unchanged.