2890 LaLoma Drive
Rancho Cordova, CA 95670
(916) 363-9454

Cordova Pet Clinic
2890 LaLoma Drive
Rancho Cordova, CA 95670
(916)363-9454

New Client Check In

 If you would like to make to become a boarding or grooming client, you can save time at check in by submitting this form.  Also, you may submit this form after business hours and we will call to assist you.

Thank you for your cooporation in letting us assist you.

Form - Cordova Pet Clinic New Client

Name & Email (required)
First Name (required)
Last Name (required)
Address (required)
Street Address (required)
City (required)
State/Province (required)
Zip/Postal Code (required)
,
Daytime Phone (required)
Phone TypePhone Number (required)
Evening Phone (required)
Phone TypePhone Number (required)
E-Mail Address :
Pet's Name (required)

Age: Years, Months

Type of Pet (required) :
Breed:

Sex: (required)
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 Veterinary Practice

May we request records?
Yes
No

Would you like us to contact you?
What services were you interested in?

Special requests or conditions?

Please list any additional pets here

Please 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 Cordova Veterinary Hospital and that charges are due and payable at the time of service, unless other arrangements are made in advance. 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 Cordova Veterinary Hospital's collection agency, and will incur a 25% collection fee for which I am liable, in addition to monthly finance charges.
I have read this statement and -
I Agree
I Disagree


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