New Client FormOwner's Name* First Last Email* Phone*Spouse/Co-Owner Name First Last Spouse/Co-Owne PhoneAddress* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Preferred method of contact*EmailPostal MailHow did you hear about us?* Location Previous client of Dr. Happel Grand Rapids Business Journal Sign/Driveby Facebook Yellowpages Grand Rapids Area Chamber of Commerce MyGRCityPoints Google Search Community Event Website Eastown Street FairWho? So we can thank them!Which community event?Pet InformationName*Color/Description*Breed*Sex:*MaleFemaleNeuteredSpayedIs your pet microchipped?*YesNoAdd another pet?*YesNoName*Color/Description*Breed*Sex:*MaleFemaleNeuteredSpayedIs your pet microchipped?*YesNoAny allergies to vaccine or medications?*YesNoDescribe belowAny previous illnesses or surgeries?*YesNoDescribe belowIs your pet on any diet or special medication?*YesNoDescribe belowPrevious veterinarian information:I give permission for Eastown Veterinary Clinic to share photographs or case specific information about my pet in all media (including promotion, advertising, sale, publicizing, and general marketing of Eastown Veterinary Clinic).* Yes No* I understand and agree to pay for services at the time that they are performed. Also, I understand that if I pay with a check and my check is returned due to non-sufficient funds, then I will be charged a $35.00 returned paypent processing fee.* I understand that if I fail to show up for my pet's scheduled appointment without notifying Eastown Veterinary Clinic, I will be charged a No Show Fee of $50.00. I also understand I will be responsible for paying the said fee of $50.00.