New Client Registration Form"*" indicates required fieldsThank 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 InformationName* First Last Address Street Address Apt# City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Primary PhoneSecondary PhoneEmail How do you prefer to be contacted? Email Text Message Phone CallMay we contact your previous veterinarian to obtain medial records? Yes NoClinic NamePhonePet InformationPet InformationNameSpeciesAgeSex (M/F)Altered (Y/N)BreedColor(s) Add RemoveLivestock and Horse InformationAnimal NameDOB/AgeSpecies Bovine Equine Ovine CaprineSex: Female Male Male-CastratedBreedColor(s)Reason for VisitPlease explain what brings you in todayPrevious Patient Medical HistoryWe AcceptCash / Visa / Mastercard / Discover / American Express / Care CreditWe 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.Signature*Date* MM slash DD slash YYYY Permission to use PhotosWe 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.I wish to DECLINE Holdenville Veterinary Clinic the ability to post any pictures and/or videos of me or my pet.CommentsThis field is for validation purposes and should be left unchanged.