Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Primary Phone *

Secondary Phone

Email *

Driver’s License *

Driver’s license is needed for writing checks and certain medications

Social Security Number *

Social security number is needed for writing checks and certain medications.

Date of Birth *

Birthday is needed for writing checks and certain medications.

Employer

Additional Owner

First

Last

Phone

Pet Information

Pet's Name *

Species *

Dog
Cat

Breed *

Color *

Age/Date of Birth *

Sex

Male
Neutered Male
Female
Spayed Female

Does your pet have a microchip identification?

Yes
No

Microchip Number

If known

How long have you owned this pet?

Did you bring previous vetting records with you for your pet?

Yes
No

Which vet, so we may call for record

ALL PAYMENTS ARE DUE AT TIME OF SERVICES

Pleas indicate your method of payment:

Cash
Personal Check
Credit/ Debit Card
Care Credit

Financial Responsibility Agreement: I understand that I am responsible for all charges for the care of my pet(s) provided by Chateau Dog & Cat Hospital. I understand that a minimum finance charge of $5.00 monthly, will be charged on any past due balance should the account become 30 days delinquent. I understand a $40 fee will be assessed for any returned checks and added to the account. I understand that if any unpaid balance is assigned to a third-party collection agency for collection or placed with an attorney to obtain a judgment or otherwise satisfy payment of my account a collection fee of 35% will be added to my account. I agree to pay that fee. I further agree to pay reasonable attorney fees and court costs. I understand the above terms.

Owner Signature *

Clear Signature

Co-owner Signature

Clear Signature

Date

Social Media Consent:

We do enjoy taking pictures and videos of our patients and their families. By signing, you authorize the use of such photos and videos for advertising and web use on our website and Facebook page.

Please check the box that applies

Authorize use of photos and videos
Decline use of photos and videos

Signature

Clear Signature

Date

New Client Form

New Client Form

Pet Information

ALL PAYMENTS ARE DUE AT TIME OF SERVICES

Social Media Consent:

We proudly cater to the Indiana communities of
Mt. Vernon, Boonville, Newburgh, Princeton, and
Ft. Branch, as well as Henderson, Kentucky.

Request an Appointment Online!

Have a question?

New Client Form

New Client Form

Pet Information

ALL PAYMENTS ARE DUE AT TIME OF SERVICES

Social Media Consent:

We proudly cater to the Indiana communities ofMt. Vernon, Boonville, Newburgh, Princeton, andFt. Branch, as well as Henderson, Kentucky.

We proudly cater to the Indiana communities of
Mt. Vernon, Boonville, Newburgh, Princeton, and
Ft. Branch, as well as Henderson, Kentucky.