New Client InformationPlease complete the form below and submit before your first appointment. Owner name * First Name Last Name Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Email address * Primary phone * (###) ### #### Optional phone (###) ### #### Drivers license # / expiration date / state issued Pet insurance / policy # Do you qualify for senior discount programs (65+)? * Select one Yes No How did you hear about Stayton Veterinary Clinic? Select one Referral Web Search Social Media Can we use photos of your pet(s) on our social media? Select one Yes No PET INFORMATION Pet name * Breed * Sex * Select one Male Female Spayed / neutered? * Select one Yes No Color * Age * PAYMENT INFORMATION Preferred payment method * Select one Cash Check Credit Card Care Credit By typing my name in the field below, I acknowledge that all charges must be paid in full before my pet will be released from Stayton Veterinary Hospital. Any remaining unpaid balance turned over to collections may be subject to a 100% increase at the discretion of Santiam Canyon VetMed, P.C. If payment is not made as agreed, client shall be responsible for any and all interest at 1.5% per month or 18% per annum., reasonable attorney fees, cost of collection and court costs incurred in efforts to enforce this agreement. * Your form has been sent successfully. Please be sure you have also completed the Medical History Form before your first visit.
