479-579-2150 contactus@midcitiesanimalhospital.com

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New Client Form

Thank you for giving us the opportunity to care for your pet(s).
So that we may become better acquainted, please complete the following form.

Get Started

New Client Form

Name *

First

Last

Spouse/Co-Owner’s Name

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Email *

Phone *

Place of Employment

Best Time to Reach You *

Work Phone

Spouse/Co-Owner’s Work Phone

All Fees Are Due At the Time Services Are Rendered *

I agree and understand

Please indicate choice of payment *

Cash / Check
Visa
MasterCard
Care Credit

How did you become aware of our clinic? *

Drove by
Website
Client
Facebook
Google
Yelp
Yellow Pages
Personal Recommendation
Other

Who may we thank?

Pet(s) Information

Name *

Species *

Dog
Cat

Breed *

Date Of Birth *

Color *

Sex; Spayed or Neutered? *

Dog Vaccinations

RABIES
DHLP PARVO
BORDETELLA
FECAL (STOOL SAMPLE)
HEARTWORM TEST/PREVENTION

Cat Vaccinations

RABIES
DIST-RHINO CHLAMYDIA
LEUKEMIA TEST
FECAL (STOOL SAMPLE)

Would you like to add a 2nd pet? *

Yes
No

Name *

Species *

Dog
Cat

Breed *

Date Of Birth *

Color *

Sex; Spayed or Neutered? *

Dog Vaccinations

RABIES
DHLP PARVO
BORDETELLA
FECAL (STOOL SAMPLE)
HEARTWORM TEST/PREVENTION

Cat Vaccinations

RABIES
DIST-RHINO CHLAMYDIA
LEUKEMIA TEST
FECAL (STOOL SAMPLE)

Would you like to add a 3rd pet? *

Yes
No

Name *

Species *

Dog
Cat

Breed *

Date Of Birth *

Color *

Sex; Spayed or Neutered? *

Dog Vaccinations

RABIES
DHLP PARVO
BORDETELLA
FECAL (STOOL SAMPLE)
HEARTWORM TEST/PREVENTION

Cat Vaccinations

RABIES
DIST-RHINO CHLAMYDIA
LEUKEMIA TEST
FECAL (STOOL SAMPLE)

Our pet(s) is: *

Indoor Only
Outdoor Only
Equally Indoor/Outdoor
A Child’s Pet

Any previous serious illnesses or surgeries? *

Any allergies to vaccinations or medications? *

Is your pet on any special diets or medications? *

Would you like to be present during treatment to your pet? *

Yes
No

Signature *

Clear Signature

Date *

Website

Request an Appointment

We deliver veterinary care with respect and compassion to the pets of Bentonville, Rogers, Centerton, Cave Springs, Springdale, Lowell, and beyond. Easily request an appointment for your pet using our online system on PetDesk and keep up with your pet’s health by downloading our app!

Appointment Download App

Have a question?

Complete our online form, and a member of our team will be in touch with you shortly.

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Where to Find Us

2805 SW 14th St, Ste 1
Bentonville, AR 72712



How to Reach Us

479-579-2150
…or email us



Our Hours

Mon–Fri: 7:30 am to 6 pm
Saturday: Closed
Sunday: Closed

Name *

First

Last

Email *

Phone

How can we help you? *

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