Coastal Valley Veterinary Services

PO Box 1015
Old Lyme, CT 06371

(860)867-6367

coastalvalleyvet.com

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 cooperation in letting us assist you.

New Client

Name (required)
First Name (required)
Last Name (required)
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 :
Pet's Name (required)

Age: Years, Months (or date of birth if known)

Species (required) :
Breed:

Sex: (required)
Male
Female


Neutered/Spayed
Neutered
Spayed


Are vaccines current?
Do you have medical records?
Medical records at another Veterinary Practice?
Yes
No


Name of former Veterinary Practice

May we request a transfer of records?
Yes
No


Would you like us to call you for your appointment
reasons or conditions that prompted your visit?

Special requests or conditions?

Please list any additional animals here

Please Read
I understand, by indicating I agree and submitting this registration, that I am responsible for any charges incurred while my animal(s) are in the care of Coastal Valley Veterinary Services, LLC and that charges are due and payable at the time of service. 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 Coastal Valley Veterinary Services, LLC'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 -
I Agree
I Disagree



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