Your Cape Cod Veterinarian

New Client Form

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Online Forms

Leach Animal Hospital

New Client Form

This lets us record our pets and owners into our management software so that we can effectively and efficiently provide the service you deserve!

Name *

First

Last

Spouse/ Other *

First

Last

Email *

Primary Phone *

Secondary Phone *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Employer *

Employer Street Address *

Address Line 1

Address Line 2

City

State

Zip Code

Employer Phone *

Owner's Driver's License # *

(kept confidential - for check writing privileges only)

State *

How did you first hear about Leach Animal Hospital? *

Friend/Referral
Sign (drive-by)
Google
Social Media
Other

Whom may we thank for referring you? *

If Other, please explain. *

PROFESSIONAL FEES ARE DUE AT THE TIME SERVICES ARE RENDERED

• I request that Leach Animal Hospital, PC veterinarians and staff perform the services which are necessary to the examination and medical treatment of the animal(s) presented by me. I am the owner or agent for the owner of the described animal(s) and have authority to execute this consent. Provider is hereinafter understood to mean Leach Animal Hospital, PC, its veterinarians, agents, and employees. • I authorize the veterinarians on duty (and assistants they may designate) to examine the animal(s) and to administer medical treatment or emergency care which is considered therapeutically and/or diagnostically necessary on the basis of the examination findings. I, therefore, hereby consent to and authorize the performance of such procedures as deemed necessary and desirable in the veterinarian’s professional judgment. • I understand that the treatment of the patient(s) will be conducted with due care and in accordance with the prevailing standards of care in veterinary medicine. I certify that no guarantee or assurance has been made as to the results that may be obtained through the course of treatment undertaken by the Provider. • Accounts over 30 days past due shall pay interest at the maximum legal rate. I agree to pay all attorney’s fees, interest, collection costs and other costs of litigation incurred in the collection of past due accounts. This agreement shall be construed by the laws of Massachusetts and the trial courts of Barnstable County shall have original jurisdiction over any disputes involving this agreement. • The Provider shall not be responsible for the loss, theft or destruction of any personal property left with my pet(s). • I understand that an estimate may be provided at my request. I also consent to the release of medical information to other authorized veterinary and/or boarding facilities. • I assume financial responsibility for all charges incurred to the patient for services rendered and understand that full payment is required upon discharge. • I authorize any person with possession of the described animal(s) in addition to myself to request veterinary care for the described animal(s) and have the authorization to make medical decisions for the described animal(s) in my absence. In addition, I understand all services/products rendered by that person will be my financial responsibility. *

I have read and accept the financial policy.

Signature *

Date *

Animal Medical History

Pet's Name *

Species (dog, cat, etc.) *

Breed *

Color *

Age/Date of Birth *

Sex *

Male
Neutered Male
Female
Spayed Female

Vaccination History: Dog (please give dates of last vaccinations)

DHLP/PARVO

RABIES

LYME

HEARTWORM TEST

FECAL

DISTEMPER

Vaccination History: Cat (please give dates of last vaccinations)

RVRCP

RABIES

LEUKEMIA

FELV/ FIV TEST

FECAL

Name of veterinarian who gave vaccinations *

Phone *

Has your pet had any previous serious illnesses or surgeries? *

Does your pet have any allergies to vaccinations or medications? *

Is your pet on any special medications or diets? *

Has your pet ever shown aggressive behavior toward people or other animals? If so, please explain: *

Is your pet currently taking heartworm prevention? *

Do you brush your pet’s teeth? *

Date of last professional Dental Cleaning *

Does your pet have a microchip identification? *

What is the microchip number? *

Comment

We’re Excited to See you

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We provide exceptional veterinary care for your furry family member and treat them like our own. We proudly service the pets of Mashpee, Sandwich, Falmouth, and Barnstable.

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Contact Us

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Contact

P: 508-477-3320
E: leachanimal@gmail.com
F: 508-477-2216

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Address

482 Main St, Mashpee, MA 02649

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Hours

Mon – Fri: 8 AM – 5 PM
Open Select Saturdays: 8 AM – 3 PM

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Email *

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How can we help you? *

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