Client Information Form

Welcome to Dallas Animal Clinic! Please complete your online client form before your first visit. If you need immediate assistance, please call us directly at 503-623-3943.

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New Client Form

Name *

First

Last

Email *

Primary Phone *

Secondary Phone

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Driver’s License #

Employer Information

Employer

Work Phone

Work Email

Employer Address

Address Line 1

Address Line 2

City

State

Zip Code

Spouse/Partner Information

Name

First

Last

Primary Phone

Spouse Employer

Spouse Work Phone

Other

Preferred Method of Contact

What time of day is best to contact you:

Morning
Mid-Day
Evening
Anytime

Do you have Pet Insurance?

How did you become aware of our Clinic?

Emergency Contact Information

In my absence the following people have permission to have my pet treated by Dallas Animal Clinic:

Emergency Contact Name

First

Last

Phone

Second Emergency Contact Name

First

Last

Phone

Financial Policy

Dallas Animal Clinic financial policy is payment is due at time service is rendered. Accepted forms of payment are Cash, Debit, Visa, MasterCard, American Express, and Discover. Care Credit, a medical credit card, can be applied for and Is offered through our office. Please be sure to talk with our reception staff about any questions or concerns about payment. Should your pet require hospitalization or surgery, an estimate of the medical costs will be given to you if able. We require a deposit of at least 50% of the estimated cost upon the admittance of your pet to our hospital. The balance must be paid at the time your pet is discharged. If you foresee financial limitations regarding your charges, please notify a staff member as soon as possible. Unpaid balances kept beyond 30 days will be subject to a billing fee of $10 and a finance charge not exceeding 9% APR. *

I have read and accept the financial policy.

Signature *

Clear Signature

Date *

Client Information Form

New Client Form

Employer Information

Spouse/Partner Information

Other

Emergency Contact Information

Financial Policy

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Hours

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