New Client Form

Save some time!

We’re here to make your life easier. Complete your new client form online and make your first visit to Village Gate Animal Hospital that much easier!

Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Email *

Primary Telephone *

Secondary Telephone

Your Driver’s License Number and State

Emergency Contact (Name and Phone Number)

How do you prefer to be notified of reminders?

Phone Message
Email
Post Card

How did you first learn of our hospital? We would like to thank any individual who referred you.

Fees are due at the time services are rendered. We accept cash, debit cards, VISA, MasterCard, American Express and Care Credit. Fees: We accept checks drawn from a local bank with special permission. We charge a $50 fee for returned checks. Furthermore, in the event you refuse or otherwise fail to make payment owed for services rendered by us in caring for your pet, you are responsible for any and all costs of collection incurred by us, including attorney’s fees, to collect payment(s) from you. Estimates: At your request, we will gladly discuss cost of services and/or prepare a written estimate for recommended procedure. *

I have read and understand.

Photo and pet name release: By checking below, I hereby give Village Gate Animal Hospital & Pet Resort the right to use the name, video and photograph of any of my pets in connection with its website and any promotional materials in any and all media, including printed material, internet, social media, and film for display, public relations and marketing. I hereby acknowledge receipt of adequate consideration and waive the right (i) to charge or be compensated for use of the pictures, and my pet(s)’s name and (ii) to inspect or approve the images prior to any form of usage. I understand that the images may be modified to use as design elements. *

I have read and give permission
I have read and DO NOT give permission

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