Detroit Veterinarian - Pet Clinic - New Client

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Harvey Animal Hospital

18479 Mack
Detroit, MI 48236

(313)882-3026

www.harveyanimalhospital.com

New Client Form or Email your pets records to Harveyah1@gmail.com

If you would like to make an appointment, you can assist us to expedite your check in by submitting this form.

Thank you for your cooperation in letting us assist you.

New Client

Name *(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 Type	Phone Number (required)

Alternate Phone (required)
Phone Type	Phone Number (required)

E-Mail Address (required) :

How did you hear about us? (required)

Appointment :

Pet's Name (required)

Age: Years, Months (required)

Type of Pet (required) :

Breed: (required)

Sex: (required)
Male
Female

Neutered/Spayed (required)
Neutered
Spayed

Are your pets vaccines current?

Do you have your pets medical records?

May we contact your previous veterinary hospital to get records? (required)
Yes
No

Name of Former Veterinary Practice (required)

Would you like us to call you for your appointment

Reasons or conditions that prompted your visit? (required)

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 harvey and that charges are due and payable at the time of service, unless other arrangements are made in advance. Any balance that is carried over a period of 30 days will accrue a monthly finance charge of 1.5% per annum. Any balance that I leave unpaid will be forwarded to Harvey's collection agency, and will incur a $25 collection fee for which I am liable, in addition to monthly finance charges.

I have read this statement and - (required)
I Agree
I Disagree

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