New Client Form

Welcome to Mill Pond Veterinary Clinic & Kennel. If you’re a new client in the Quakertown area, completing this form is the first step to becoming part of our practice. Once we receive your information, our team will reach out to schedule your pet’s first appointment.

Become a Client

New Client & Patient Information

Please complete this form for each pet before requesting your first appointment. We ask that all prior veterinary records be emailed to our office and that this paperwork be submitted through our web portal at least 48 hours before your scheduled visit. Once your forms are received, our team will call to schedule.

Client Name *

Name provide Party

Spouse/Other:

Address

Address Line 1

Address Line 2

City

State

Zip Code

Primary Phone

Alternate Phone

Email *

Driver's License Number

State

Employer's Name and Address:

Address Line 1

Address Line 2

City

State

Zip Code

Emergency Contact and Phone

How did you first hear of our practice?

If referred to our practice, please provide who referred you:

PAYMENT INFORMATION:

Ensuring that our patients receive high quality care is the goal of our practice. To help us be able to perform such care, payment is due at the time of treatment. We accept cash, check, and major credit cards. Please indicate below your preferred form of payment to settle your account:

CASH OR CHECK
MAJOR CREDIT CARD

Signature of Client/Responsible Party *

Clear Signature

Date *

New Client Form

New Client & Patient Information

PAYMENT INFORMATION:

Schedule Your Pet’s Visit Today

Have a Question?

Location

Contact Information

Hours