New Patient Information Form New Patient Information Form Step 1 of 2 50% Your InformationLast Name*First Name*Email* Home Phone*Work PhoneEmergency PhoneAddress* Street Address City State / Province / Region ZIP / Postal Code Spouse Name or Alternate contact PersonSpouse PhoneHow did you find us?*FriendGoogle / InternetYellow PagesWalk InWhom can we thank for the referral?* Patient InformationPet's Name*My Pet is a...*Type of PetDogCatOtherGender*Select One...MaleFemaleNeutered or Spayed?Select One...YesNoDate of Birth* MM DD YYYY Breed*Color of your pet*Payment Method*CashATMVisa/MastercardDiscoverAmexCare CreditPreferred Veterinary Location*Please select one...Deer Valley - 5151 Deer Valley Rd., Antioch CA10th Street - 1432 W. 10th St., Antioch CASignature*I assume responsibility for all charges incurred in the care of my pet(s). I also understand that these charges will be paid at the time of release and that a deposit will be required for any treatment that the pet must be left for. A billing fee and interest feed of 11/2% per month, which is an Annual Percentage Rate of 18%, will be charged on any unpaid balance. I further assume responsibility for any collection fee or attorney’s fees necessary to collect the full amount.