(937) 836-4432
northmontanimalclinic@gmail.com
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For Questions, Don’t Hesitate to Give Us A Call at (937) 836-4432

We will be open 8am – 5pm on Sunday, December 24th. We will be closed Monday, December 25th for Christmas!
Request pick-ups 30 minutes prior to closing.

NEW CLIENT FORM

Save time during your new client appointment. Complete your required form online from any device at any time before your visit.

New Client Form

Please fill out this form as completely and accurately as possible so we can get to know you and your pet before your visit.

Name *

First

Last

Email *

Primary Phone *

Secondary Phone

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Who else is authorized to make decisions about your pet's healthcare? *

First

Last

Phone

How did you find out about our hospital? If you were referred by someone, who should we thank? *

Pet's Name *

Species (dog, cat, etc.) *

Breed *

Age/Date of Birth *

Sex *

Male
Neutered Male
Female
Spayed Female

Does your pet have a microchip identification? *

Yes
No

What is the microchip number?

Do you have a second pet? *

Yes
No

Pet's Name *

Species (dog, cat, etc.) *

Breed *

Age/Date of Birth *

Sex *

Male
Neutered Male
Female
Spayed Female

Does your pet have a microchip identification? *

Yes
No

What is the microchip number?

Do you have a third pet? *

Yes
No

Pet's Name *

Species (dog, cat, etc.) *

Breed *

Age/Date of Birth *

Sex *

Male
Neutered Male
Female
Spayed Female

Does your pet have a microchip identification? *

Yes
No

What is the microchip number?

Do you have a fourth pet? *

Yes
No

Pet's Name *

Species (dog, cat, etc.) *

Breed *

Age/Date of Birth *

Sex *

Male
Neutered Male
Female
Spayed Female

Does your pet have a microchip identification? *

Yes
No

What is the microchip number?

Do you have a fifth pet? *

Yes
No

Pet's Name *

Species (dog, cat, etc.) *

Breed *

Age/Date of Birth *

Sex *

Male
Neutered Male
Female
Spayed Female

Does your pet have a microchip identification? *

Yes
No

What is the microchip number?

Payment is due in full at the time that services are performed. If being admitted into the hospital, we cannot begin the care of your Pet until you have confirmed your desire to do so by 1) signing the client consent & estimate form, and 2) leaving an initial deposit of 50% of the upper end of the estimate. This is the only way that we have of knowing for certain that you want us to proceed with the care of your Pet. We accept Creditcard, Cash, Check, and CareCredit payments. We neither extend credit, nor bill for services. All open invoices are sent to collections after 45 days unless prior arrangements are made. *

I have read and accept the financial policy.

Message

Ready for a Visit?

When you’re ready to schedule an appointment for your furry companion, give us a call, and our friendly staff will be delighted to assist you.

Request an Appointment Online

With a few simple clicks, you can easily request an appointment online, and our team will promptly follow up to confirm the details of your pet’s visit.

Questions?

For questions or concerns, please fill out the form, and a member of our team will be in touch shortly.

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Address

75 W. Wenger Rd.
Englewood, OH 45322

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Phone

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E-Mail

northmontanimalclinic@gmail.com

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Mon–Fri: 8am–6pm
Sat: 8am–12:00am
Sun: Closed

Name *

First

Last

Email *

Phone

How can we help you? *

Email

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