Dr. Rae's Veterinary Housecalls

327 Citrus Open Drive
New Smyrna Beach, FL 32168

(386)957-2622

www.drraehomevet.com

New Client Check In

If you would like to make an appointment, you can assist us to expedite your check in by submitting this form.

Thank you for your cooporation in letting us assist you.

New Client

Name & Email (required)
First Name (required)
Last Name (required)
Address (required)
Street Address (required)
City (required)
,
State / Province (required)
Zip / Postal Code (required)
Daytime Phone (required)
Phone TypePhone Number (required)
Evening Phone (required)
Phone TypePhone Number (required)
E-Mail Address :
Pet's Name (required)

Age: Years, Months

Type of Pet (required) :
Breed:

Sex: (required)
Male
Female


Neutered/Spayed
Neutered
Spayed


Are your pets vaccines current?
Do you have pets medical records?
Medical records at another veterinary Practice?
Yes
No


Name of Former Veterinary Practice

May we request a transfer of records?
Yes
No


Would you like us to call you for your appointment
Reasons or conditions that prompted your visit?

Special requests or conditions?

Please list any additional pets here

Please Read
I, the undersigned, and owner or authorized agent of the above mentioned pets, do hereby authorize Dr Rae's Veterinary Housecalls to perform such examinations, diagnostic tests and treatments as necessary. I further agree to be financially responsible for all costs for such procedures and treatments. I understand that full payment is due at the time services are rendered. Failure to pay bills on time may result in billing, finance charges and/or costs of any collection fee incurred.
I have read this statement and -
I Agree
I Disagree



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