Highland Veterinary Clinic / Automated Prospective Client Check-In

Highland Veterinary Clinic
6805 Darmstadt Road
Evansville, IN 47710
(812)867-6651

Highland Veterinary Clinic

Welcome to Our Site

Prospective Client Check In

If you would like to make an appointment, you can assist us to expedite your check in by submitting this form. The New Client form is still required. It is available under "Forms to Print and Bring With You." However, this form allows us to gather your pet's medical history prior to your visit.

Thank you for your cooporation in letting us assist you.

Form - New Client

Name & Email (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 Type	Phone Number (required)

Evening Phone (required)
Phone Type	Phone Number (required)

E-Mail Address :

Pet's Name (required)

Age: Years, Months

Type of Pet (required) :

Breed:

Sex: (required)
Male
Female

Neutered/Spayed
Neutered
Spayed

Microchip or Tattoo?
HomeAgain
Avid
Bayer
Tattoo
None

Microchip or Tattoo ID Number

Are your pets' vaccines current?

Do you have your pets' 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 pets here

Please Read
I understand, by indicating I agree and submitting this registration, that I am responsible for any charges incurred by my pet while in the care of the doctors at Highland Veterinary Clinic and that charges are due and payable at the time of service, unless other arrangements are made in advance. 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 Highland Veterinary Clinic'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 - (required)
I Agree
I Disagree

The verification code below ensures the form is not submitted by a computer

Verification Code :

Enter the code you see in the graphic below in this box.
Your post will not be allowed if you do not type this in correctly.