New Client Form

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New Client Form

Please fill out this form as completely and accurately as possible so we can get to know you and your pet(s) before your visit.

Date

Name *

First

Last

Co-Owner/Spouse Name

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Work Phone

Co-Owner/Spouse’s Phone

Co-Owner/Spouse’s Work Phone

Email *

YOUR DRIVERS LICENSE IS REQUIRED AT REGISTRATION FOR IDENTIFICATION AND INFORMATION VERIFICATION. ALL FEES ARE DUE AND PAYABLE AT THE TIME SERVICES ARE RENDERED. WE DO NOT OFFER FINANCING OR IN-HOUSE CREDIT!
We accept the following forms of payment: Cash, Visa, Mastercard, Discover, American Express and Care Credit.

How did you become aware of our clinic?

Yellow Pages
Sign
Newspaper
Internet
Clipper Magazine
Flyer

Personal Recommendation (Whom may we thank?)

Do you have pet insurance? If so, which company do you use?

If yes

Occasionally, photos of pets are included on our website and our Facebook page. In order for your pet’s image to be included in either of these areas, DCAC, Inc. must have your written permission on file. Check One:

YES, DCAC, Inc does have permission to use images of my pet on the website and Facebook page.
NO, DCAC, Inc does NOT have permission to use images of my pet on the website and Facebook page.

Layout

Pet 1

Name

Species

Dog
Cat
Bird
Other

If other

Breed

Color

Age

Sex

Male
Female

Has your pet been spayed or neutered?

Special Diet/Medications:

Date of last known vaccinations:

Where were they administered?

What vaccs were administered?

Pet 2

Name

Species

Dog
Cat
Bird
Other

If other

Breed

Color

Age

Sex

Male
Female

Has your pet been spayed or neutered?

Special Diet/Medications:

Date of last known vaccinations:

Where were they administered?

What vaccs were administered?

Please note: Current vaccinations by a licensed veterinarian are required for the admission of your pet to our hospital. Owner administered vaccinations are not acceptable. This includes admission for elective surgery, boarding, grooming and well animal care. Proof of vaccinations is required prior to admission and is the responsibility of the client.

I agree to allow the doctors and staff of Precious Paws Animal Hospital to treat my pet and I accept responsibility for all accumulated fees associated with the care that my pet(s) receive. I understand that I am responsible for payment in full prior to discharge according to Precious Paws Animal Hospital policy and will be held responsible for service or collection fees if balance is not paid in full. *

I agree

Client Signature

Date

Phone

Ready for a visit?

We want people and their pets to feel at home at our animal hospital in Southaven, MS. We advance veterinary medicine without losing the family atmosphere that is so important to providing patients with high-quality care. Use our online system to book an appointment!

Book Appointment

Questions?

Get in touch! Complete our online form, and a member of our team will be in touch with you shortly.

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Location

3949 Getwell Rd, Southaven, MS 38672

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Contact Information

P: 662-996-4545
E: info.ppah@yahoo.com

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Hours

Mon-Fri: 7:00 am – 5:00 pm
Closed for lunch 12:30 -1:30 pm
Sat: 7:00 am – 11:00 am
Sun: Closed

Name *

First

Last

Email *

Phone

How can we help you? *

Phone