New Client Form

Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email*
Daytime Phone*
Phone number*
Evening Phone*
Phone number*
Pets's Name*
Age: Years, Months
Type of Pet*
Breed
Sex*
- Male
- Female
Neutered/Spayed
- Neutered
- Spayed
- Are your pets' vaccines current?
- Do you have pets' medical records?
Medical records at another veterinary Practice?
- Yes
- No
Name of Former Veterinary Practice
May we request a transfer of records?
- Yes
- No
- Would you like us to call you for your appointment
Reasons or conditions that prompted your visit?
Special requests or conditions?
Please list any additional pets here
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 Richfield Area Pet Clinic, LLC and that charges are due and payable at the time of service. Any balance that is carried over a period of 30 days will accrue a monthly finance charge of 1.5% or 18% per annum. Any balance that I leave unpaid will be forwarded to Richfield Area Pet Clinic, LLC's collection agency and/or attorneys, and I will be responsible for all associated collection costs, in addition to the unpaid balance and finance charges.
I have read this statement and*
- I Agree
- I Disagree
Captcha

Richfield Area Pet Clinic, LLC
1275 Morgan Drive
Hubertus, WI 53033

Phone: 262-628-7272

Monday - Thursday: 8:00 AM - 5:30 PM
Friday: 8:00 AM - 4:30 PM
Saturday - Sunday: Closed