New Client


	Middlebrook Animal Clinic

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.

However, we do ask for adequate time for our website administrator to "check" for form submissions. If you know that your appointment may be crunched for time because of other tasks you need to complete, make sure to call us at 691-8577 and let us know you've submitted your form.

Form - New Client

Name (required)
First Name (required)	Last Name (required)

Additional Name on Account
First Name	Last Name

Relationship:

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 *For access to our FREE PetPortal* :

Pet's Name (required)

Age: Years, Months

Type of Pet (required) :

Breed:

Color:

Sex: (required)
Male
Female

Neutered/Spayed (required)
Neutered
Spayed
Unknown

Are your pets vaccines current?

Do you have 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 Middlebrook Animal 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 Middlebrook Animal 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 -
I Agree
I Disagree

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Middlebrook Animal Clinic
9229 Middlebrook Pike
Knoxville, TN 37931
(865)691-8577