Welcome to Newington Veterinary Clinic!
To make sure we have the most up to date contact information, please fill out this form prior to your appointment. Thank you!
Primary Contact Name (Owner) *
For existing clients: Is this a new last name? If so, please give us the previous last name on your account.
How should we address you? *
Full Address (including street, city and zip code) *
Phone number *
Are you 65 years or older?
Clear selection
Secondary Contact
Relationship to Primary Owner
Clear selection
Secondary Contact Phone Number
Any other phone numbers you would like us to have on file? (Please note the name of the person we would be calling at that number)
At any time we may be taking photos to post to our Facebook page, Instagram account, website, newsletter or other clinic materials. We never include personal information and only use first names. Do we have your permission to take photos of your pet(s)? *
Payment Policy: Payment is required at the time of service. We accept cash, check, debit cards, Visa, Mastercard, CareCredit and Scratchpay. We DO NOT accept American Express or Discover *
I understand that if costs are a concern, I can ask for an estimate prior to services being rendered. *
I hereby authorize the veterinarian to examine, prescribe for or treat my pet(s). I assume responsibility for all charges incurred in the care of my pet(s). I also understand that these charges will be paid in full at the time of service and/or release and that a deposit may be required for hospitalization or surgical treatment. I also understand that any check returned for non-payment will incur a return check fee in the amount of $25 per check. If for any reason your account should go unpaid for more than 30 days, there will be a 1.5% interest charge per month. *
Never submit passwords through Google Forms.
This form was created inside of Newington Veterinary Clinic. Report Abuse