New Client Form with Mansfield Animal Hospital

Mansfield Animal Hospital

619 East Street
Mansfield MA 02048
Ph. 508.339.5775
Fax 508.339.5776
Click here to email us

Hours:
Mon, Tues, Wed
& Fri 8 am to 5 pm
Thurs 8 am - 11 am
Sat. 8am - 11 am

CLOSED ON SUNDAYS

After Hours Care

The doctor and staff of
Mansfield Animal Hospital
are happy to hear from
you regarding your pet
care needs. We are
always here to help and
even when we are closed,
you have access to quality
emergency care at:

Tufts Veterinary Emergency Teatment & Specialties
525 South St.
Walpole, MA 02081
508-668-5454
website

Animal Emergency Center
595 W. Center St.
West Bridgewater, MA 02379
508-580-2515
website

Tour our Facility Mansfield Animal Hospital

Form - New Client - Mansfield Animal Hospital

Name
First Name	Last Name

Spouse/Other
First Name	Last name

Address
Street Address


City/Town	State/Province	Zip/Postal Code
,

E-Mail Address :

Phone Information
Phone Type	Phone Number

Emergency Contact
First name	Last name

Phone Type	Phone Number

Employer

Driver's License # (required for checks)

Date of your confirmed appointment

** Payment is required at time of service. We accept VISA, Discover, MasterCard, Checks and Cash. We do not bill **

*** Due to the risk of spreading diseases and parasites, all pets admitted to the hospital are required to be up-to-date on vaccines and free of fleas and ticks.***

**** For your pet's and others' safety, please keep your pet restrained on a leash or in a carrier. ****

Pet's Information (For additional pets please fill out our new pet form)

Pet's Name

Age: DOB/ Years, Months	Type of Pet :	Color

Breed:

Sex:	Male Female
Neutered/Spayed:	Neutered Spayed

Does Your Pet Live:
Heartworm prevention	Yes No
What type?
Flea/Tick Control	Yes No
What type?

Is your pet on any medications? Yes No

If yes, type and dose:

Any previous health issues?

Anything else we should know about your pet?

What do you feed your pet?

Are your pets vaccines current? Yes No

Do you have pets medical records? Yes No

If no, please have your records faxed to us at 508-339-5776 prior to appointment.

Do you have pet health insurance? Yes No

If yes, what is the name of the company:

Please call me to schedule an appointment for my pet.

Reasons or conditions that prompted your visit?

TERMS OF SERVICE AGREEMENT - IT IS IMPORTANT TO READ
I understand, by indicating I agree and submitting this registration, that I am responsible for any charges incurred by my pet while in the care of the doctors at Mansfield Animal Hospital and that charges are due and payable at the time of service, unless other arrangements are made in advance. I also give consent to Mansfield Animal Hospital to vaccinate my pet for Rabies as mandated by Massachusetts Law unless I present proof of vaccination at the time of my ppointment. Any balance that is carried over a period of 30 days will accrue a monthly finance charge of 1.5% or 18% per annum.

I HAVE READ THE TERMS OF SERVICE AND:
I Agree
I Disagree

Click here to print