Litchfield Veterinary Hospital
Small Animal Medicine and Surgery
289 Torrington Road
Litchfield, CT 06759
860-567-1622 ph

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

Species (required)
Canine
Feline
Rabbit
Ferret
Other

Breed: (required)

Sex : (required)
Male
Female
unknown

Neutered/Spayed
Neutered
Spayed

Date of Birth

Color

Are your pets medical records at another veterinary practice?
Yes
No

May we request a transfer of records?
Yes
No

Name of Former Veterinary Practice

Special requests or conditions?

Please list any additional pets here

Please Read
I understand, by indicating I agree and submitting this registration, that I assume all responsibility for all charges incurred by my pet while in the care of the doctors at Litchfield Veterinary Hospital and that charges are due and payable at the time of service and that a deposit may be required for surgical treatment. For your convenience, we accept checks, Visa, MasterCard and Discover. We will gladly prepare a written estimate if desired.
I have read this statement and - (required)
I Agree
I Disagree


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