Name *

First

Last

Spouse

Mailing Address *

Address Line 1

Address Line 2

City

State

Zip Code

E-mail Address *

Cell Contact *

Alternate Contact

Pet Information

Pet's Name *

Species *

Breed *

Sex *

Male
Neutered Male
Female
Spayed Female

Color *

Date of Birth/Age *

Name of any other hospital to obtain records from:

Do you have a second pet? *

Yes
No

Pet's Name *

Species *

Breed *

Sex *

Male
Neutered Male
Female
Spayed Female

Color *

Date of Birth/Age *

Name of any other hospital to obtain records from:

Do we have permission to use your pet’s picture(s) for learning and/or Social Media purposes?

Yes
No

CPR Status *

DNR
Basic live-saving measures
Advanced life-saving measures

Do you have pet insurance for any of the pets listed?

Yes
No

Company

How did you choose North Star 410 Animal Hospital?

Please specify name:

If other, please specify:

An important part of our mission is making the cost of optimal care as easy and manageable for our clients as possible by offering several payment options. North Star 410 Animal Hospital requires payment in full at the end of your pet’s examination and/or at the time of discharge.

We DO NOT offer any type of payment plan or carry open accounts, but we happily accept Cash, Check (on a case-by-case basis), Mastercard, Visa, American Express, Discover, CareCredit, and Scratchpay.

We will provide you with a written estimate of fees for any case where in-hospital treatment, emergency care, surgery, or hospitalization occurs. A deposit prior to treatment may be required. By signing below, you agree to our payment terms, verify you are the owner (or authorized agent for the owner) of the above-named pet, and consent to the initial examination and diagnostics.

Authorization *

I have read and agree

Signature *

Clear Signature

Owner Signature (18+ years of age)

Date *

NEW CLIENT FORM

New Client Form

Pet Information

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Address

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Hours