CLARK ANIMAL CARE CENTER

Clark Animal Care Center

Clark Animal Care Center
1672 Fairport-Nine Mile Point Road 
(Route 250)
Penfield, NY 14526
(585)377-1160

New Client Check In

If you would like to make an appointment, you can assist us to expedite your check in by submitting this form.

Thank you for your cooporation in letting us assist you.

Form - New Client

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

Date of Birth (required)

Type of Pet (required) :
Breed:

Sex: (required)
Male
Female

Neutered/Spayed
Neutered
Spayed

Color of Pet

Are your pet's vaccines current?
Do you have your pet's medical records? If yes, please bring these with you to your appointment.
Would you like us to call you to set up an appointment?
Reasons or conditions for your visit?

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 Clark Animal Care Center and that charges are due and payable at the time of service, unless other arrangements are made in advance.
I have read this statement and -
I Agree
I Disagree

How did you become aware of our hospital? :

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