Eastside Animal Clinic

4493 E. Tamiami Trail
Naples, FL 34112

(239)774-6400

www.eastsideanimalclinic.com

New Client Check In

If you would like to make an appointment, please call us during normal business hours to schedule one.  You can assist us to expedite your check in by submitting this new client form. Please allow a couple of days for us to receive this form. If you have an appointment the next day or the same day, please call us & let us know you filled this out so we may retrieve the information quicker.

Thank you for your cooporation in letting us assist you.

New Client

Name & Email (required)
First Name (required)
Last Name (required)
Address (required)
Street Address (required)
City (required)
,
State / Province (required)
Zip / Postal Code (required)
Daytime Phone (required)
Phone TypePhone Number (required)
Evening Phone (required)
Phone TypePhone Number (required)
E-Mail Address :
Pet's Name (required)

Age: Years, Months (required)

Type of Pet (required) :
Breed & Color: (required)

Sex: (required)
Male
Female


Neutered/Spayed (required)
Neutered
Spayed


Are your pets vaccines current?
Do you have pets medical records?
Medical records at another veterinary Practice?
Yes
No


Name of Former Veterinary Practice

May we request a transfer of records?
Yes
No


Have you already booked an appointment? (required)
Yes
No


If you've already scheduled an appointment, please let us know when it's scheduled for

Reasons or conditions that prompted your visit?

Special requests or conditions?

Please list any additional pets here

Please Read
I understand, by indicating I agree and submitting this registration, that I am responsible for any charges incurred by my pet while in the care of the doctors at Eastside Animal Clinic and that charges are due and payable at the time of service. Any balance that is carried over a period of 30 days will accrue a monthly finance charge of 1.5% or 18% per annum. Any balance that I leave unpaid will be forwarded to Eastside Animal Clinic's collection agency, and will incur a 30% collection fee for which I am liable, in addition to monthly finance charges.
I have read this statement and -
I Agree
I Disagree



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