New Client Form Thank you for your interest in joining the AHBC family! Our preliminary New Client Form will take some basic information. We’re excited to get to know you and your pet.Pet Parent's Name*Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Primary Phone*Secondary PhoneEmail* Your Pet's Name*Your Pet's Age*Species*CanineFelineAvianExoticOtherBreedSex*MaleFemaleIs your pet neutered or spayed?*NeuteredSpayedDo you have your pet's medical records?*YesNoDoes your pet have records at another vet?*YesNoPrevious VetMay we request a transfer of records?YesNoDoes your pet have any health or behavioral issues? Please describe.Please Read By indicating I agree and submitting this form, I understand I am responsible for any charges incurred by my pet while in the care of Animal Hospital at Brier Creek and that charges are due at the time of service unless other arrangements are made in advance. Any balance carried over a period of 30 days will accrue a monthly finance charge of 1.5%, or 18% per annum. Any balance I leave unpaid will be forwarded to Animal Hospital at Brier Creek'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.*I AgreeI DisagreeWould you like to request a new pet visit? After you submit the New Client Form, you can request an appointment by clicking on the REQUEST AN APPOINTMENT button at the top of any page. Thank you!NameThis field is for validation purposes and should be left unchanged.