Returning Client Form

Welcome to the Hickman Mills Animal Hospital. Please fill out this form completely to help us get to know you and your pet(s), and help us serve you better.

****In order to avoid any misunderstanding, it is important that you know you will be charged, at the minimum, an
office visit/examination fee for today’s visit. We do not accept personal checks as payment during your first 30 days as a
new or returning client. We do accept cash, most major credit cards, and Care Credit as payment. Payment must be made
today, at the time services are rendered.**** I have read and agree to the above.

Signature Required *

Sign above

Owner's Name *

Spouse/Other *

Address

Street Address *

City/Town *

State/Province *

ZIP/Postal Code *

Home Phone *

Work Phone *

Mobile Phone *

Email Address *

Your email address will be used for reminders/health care ONLY. It will never be sold or shared for marketing purposes.

You will be asked to furnish a photo ID to be photocopied for our files. If you would rather not, or if this is not possible, we will not be able to accept a personal check until you have done so.

First Pets Information

Pet’s Name *

Species *

Breeds *

Sex *

Neutered/Spayed? *

Age *

Color(s) *

Has your pet had baseline bloodwork completed in order to establish normals for him/her? *

Which Heartworm Preventative do you use? *

Which Flea/Tick Preventative? *

Second Pets Information

Pet’s Name

Species

Breeds

Sex

Neutered/Spayed?

Age

Color(s)

Has your pet had baseline bloodwork completed in order to establish normals for him/her?

Which Heartworm Preventative do you use?

Which Flea/Tick Preventative? *

Please tell us how you learned about Hickman Mills Animal Hospital? If you were referred to us by one of our clients, please share their name with us so that we may thank them personally *

****If you provided us your email address you will receive an invitation to access a FREE Petly Page within 48 hours. This willgive you 24/7 access to vaccine records, text and email reminders, you can request medical, grooming, or lodgingappointments, have access to lab reports, refill scripts, and much more!! Nothing to buy/always free.****

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Returning Client Form

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