Holdenville Veterinary Clinic
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New Client Registration Form

"*" indicates required fields

This field is for validation purposes and should be left unchanged.
Thank you for entrusting us with the care of your pets and livestock. We strive to provide the highest quality veterinary medical care for the well being of all animals. Please complete the form below and return it to the front desk to finalize registration. Feel free to ask us questions or voice your concerns, we are happy to help.

Owner Information

Name*
Address
How do you prefer to be contacted?
May we contact your previous veterinarian to obtain medial records?

Pet Information

Pet Information
Name
Species
Age
Sex (M/F)
Altered (Y/N)
Breed
Color(s)
 

Livestock and Horse Information

Species
Sex:

Reason for Visit

We Accept

Cash / Visa / Mastercard / Discover / American Express / Care Credit

We DO NOT accept checks or offer payment plans.

I authorize Holdenville Veterinary Clinic to perform procedures deemed necessary and advisable for the health and wellbeing of my pet(s) and/or livestock. I accept responsibility for all fees incurred in the care of my pet and/or livestock at the time services are rendered. In the event that it becomes necessary to refer my account to an outside collection agency, I am aware that all finance charges, collection costs, attorney fees, and other collection costs will be the responsibility of the patient’s owner.

Clear Signature
MM slash DD slash YYYY

Permission to use Photos

We love sharing pictures and videos of our wonderful patients! This includes displaying pictures and videos on our website, Facebook page, and any promotional/ educational material. If you do not wish for photos and/or videos of you and/or your pets to be displayed on the above platforms, please initial below.

Contact Us

Holdenville Veterinary Clinic

OFFICE: 405.379.5406

FAX: 405.555.5555

601 KINGSBERRY RD.

HOLDENVILLE, OK 74848

Hours

MONDAY - THURSDAY 8 AM - 5 PM
FRIDAY 8 AM - NOON (12PM)

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