New Client/Patient Form

If you are a new Client bringing a pet for the first time or an existing Client bringing a new pet for the first time, there is some paperwork that will need to be filled out. You may fill out the form on the website and it will be sent directly to us or you may download the form and print it out at home. We also have the forms available in the Clinic if you do not wish to use the ones available on the site.

New Client/Patient Form

* Indicates required field

Pet Name *

Species *

Sex *

Breed *

Color *

Date of Birth *

Previous Vaccinations/Veterianarian *

Any Known Drug Allergies/Sensitivities? *

Any Previous Major Medical/Disposition Problems? *

Reason For Visit: *

I allow our pet's picture to be on Lonestar's website/facebook page: *

Yes No

Owner's Name *

First

Last

Co-Owner/Spouse Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Phone Number 1 *

Phone Number 2 *

Phone Number 3 *

Phone Type 1 *

Phone Type 2 *

Phone Type 3 *

Email *

May All Be Used For Contact? *

Yes No

Employer's Name & Address *

Last 4 of Social Security No. *

Driver's Lic. No. * *

*A copy of license will be made in office for all new pets.

Upload Previous History *

Max file size: 20MB

Driver's Lic. State *

Spouse's Employer & Address *

Last 4 of Spouse's SS No. *

Spouse's DL No. *

Spouse's DL State *

I assume responsibility for all charges incurred in the care of this animal. I understand that these charges must be paid at the time of services unless payment arrangements are made in advance. Any balance carried is subject to a 2.0% Monthly Finance Charge and a $1.50 Billing Charge. With any payment arrangements, if the undersigned fails to make any payments due hereunder, hospital may at anytime thereafter, without notice or demand, declare the entire unpaid balance of the account to be immediately due and payable. The undersigned promises to pay all cost of collection, including, but not limited to court costs, attorneys fees equal to 15% of any amount due and owing to the hospital, and any other collection fees which are incurred by or on behalf of the hospital in enforcing payment after default. The undersigned expressly agrees and stipulates that if, in the sole discretion of the hospital, its representatives or its attorneys, litigation or court process is necessary to enforce payment hereunder, that the venue for such litigation or court process shall be the Circuit Court for Wicomico County, Maryland, or the District Court of Maryland for Wicomico County, Maryland, and the undersigned hereby expressly waives any right of venue or trial in any county or jurisdiction other than Wicomico County, Maryland.

Submit

Below is the downloadable version of the form for you to fill out at home.

New Patient/Client Form
File Size:	84 kb
File Type:	pdf

Download File

New Client/Patient Form

​New Client/Patient Form

New Client/Patient Form