New Client Form

Owner Name*
Spouse/Other
Address*
Street Address City State Zip
Phone (Primary)*
Phone (Other)
Email Address*
How did you hear about us?*
Emergency Contact Name
Phone
If a friend or family member referred you, they will receive a $50 bonus credit for their next visit. Who may we thank for referring you today?
Do you have a referring clinic you would like us to send today's records to?
Do you have a pet insurance company to send records/invoices to?
Is there a previous vet we can call for your pet's most recent medical records? If so, please provide the name of the veterinary practice and their phone number that we can call to request records.
Appointment Date
MM slash DD slash YYYY
Appointment Time
: HH
Minute
AM/PM
Pet Name*
Species*
Breed*
Color*
Gender*
Is your pet spayed/neutered?*
Birthday
MM slash DD slash YYYY
Age*
Known allergies or pre-existing conditions
Upload Pet Picture
Accepted file types: jpg, gif, pngjpeg, Max. file size: 10 MB.
Have a 2nd Pet?
Pet Name*
Species*
Breed*
Color*
Gender*
Is your pet spayed/neutered?*
Birthday
MM slash DD slash YYYY
Age*
Known allergies or pre-existing conditions
Upload Pet Picture
Accepted file types: jpg, gif, pngjpeg, Max. file size: 10 MB.
Have a 3rd Pet?
Pet Name*
Species*
Breed*
Color*
Gender*
Is your pet spayed/neutered?*
Birthday
MM slash DD slash YYYY
Age*
Known allergies or pre-existing conditions
Upload Pet Picture
Accepted file types: jpg, gif, pngjpeg, Max. file size: 10 MB.
Have a 4th Pet?
Pet Name*
Species*
Breed*
Color*
Gender*
Is your pet spayed/neutered?*
Birthday
MM slash DD slash YYYY
Age*
Known allergies or pre-existing conditions
Upload Pet Picture
Accepted file types: jpg, gif, pngjpeg, Max. file size: 10 MB.
Disclaimer*
I agree to the policy outlined below
By signing this form, I confirm and agree that I am the legal owner or the responsible party of the above-mentioned pet(s). I understand that payment for all services rendered is due at the time of treatment or services given. I understand that beginning at 30 days past due on any balance incurred, that interest charges will be assessed at 10% based on State Statute. If amounts owed exceed approximately 90 days past due, GQ may use all legal methods to recover amounts owed including the Arizona Attorney General, or a local attorney. Collection charges will be added to the account and will be the responsibility of the client. If a court ordered judgment occurs, attorney fees will also be assessed. I understand photos and/or videos of my pet(s) might be used on social media or other online sources. If you do not wish for your pet’s photos/videos to be shared on social media, please let us know that you wish to opt out and we will note your account.

Forms of payment accepted: Cash, Visa, MasterCard, Discover, Amex, Care Credit and Bank Debit Cards
Signature*

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