McCordsville Veterinary Hospital

McCordsville Veterinary Hospital

6104 W Broadway

McCordsville, IN 46055

(317) 335 - 3741

 

 

Office Hours

 Monday 

 7:30 am to 6:00 pm

 Tuesday

 7:30 am to 6:00 pm

 Wednesday

 7:30 am to 6:00 pm

 Thursday

 7:30 am to 6:00 pm

 Friday

 7:30 am to 6:00 pm

 Saturday

 7:30 am to 12:00 pm

 Sunday

Closed 

 

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
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)
Evening Phone (required)
Phone TypePhone Number (required)
E-Mail Address (required) :
Pet's Name (required)

Date of Birth (required)

Type of Pet (required) :
Breed: (required)

Color: (required)

Sex: (required)
Male
Female

Neutered/Spayed (required)
Neutered
Spayed
Unknown

Are your pets vaccines current?
Do you have pets medical records?
Medical records at another veterinary Practice?
Yes
No

Name of Former Veterinary Practice

Reasons or conditions that prompted your visit?

Do you have an appointment scheduled already? (required)
yes
no
please call me to schedule

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 McCordsville 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 McCordsville 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 - (required)
I Agree
I Disagree


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