New Client Information Form

New Client Information Form

Welcome to Irvington Pet Clinic. We are looking forward to helping you keep your pets happy and healthy. Please fill out the information below and submit to us no later than 24 hours prior to your scheduled appointment. If you have not yet scheduled an appointment, please contact our office at 317-357-6148. Thank you.

Client Information

Spouse / Co-Owner Information

Patient Information - Pet #1

Patient Information - Pet #2

If you have more than two (2) pets, we will obtain their information at the time of your scheduled appointment.

Payment Information

So that we may continue to provide the most up-to-date services for our clients, payment is due in full at the time services are rendered. Please indicate below your preferred method of payment.

Authorization For Services

I understand that by submitting this form to Irvington Pet Clinic, I am authorizing the Doctor(s) and Staff to provide veterinary care for my pet(s) presented by myself or my agents. I understand that I will be provided an estimate of current and anticipated charges at any time I request one. I understand that I am financially responsible for all services rendered and if I do not pay this account as agreed, that past due accounts are subject to costs of collections, including interest and attorney fees. Returned Check Fee is $20.00.

Enter the verification code in the box below.