New Client Form

Today's Date
Date Format: MM slash DD slash YYYY
Owner's Name
First Last
Phone Number
Owner's Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Additional Owner's Name
First Last
Additional Owner's Phone Number
Owner's Employer
Employer Phone Number
Email
Preferred Method of Contact
- Phone
- Email
- Text Message
I authorize the following persons over age 18 to seek care for and sign treatment plans regarding my animal(s):
How did you hear about us?
If Other or Personal Recommendation Specify Here
All fees are due at the time services are rendered
Authorization: I authorize Bear Creek Animal Clinic and all assistants of its choice to render and perform any necessary surgical operations and/or medical treatment upon my animal(s) as deemed necessary or advisable while my animal(s) are in custody and possession of the Hospital if I am unable to be reached. I release the Hospital and its assistants from any liability by reason of this disclaimer. I understand that veterinary service is provided after office hours as the veterinarian in charge deems it to be necessary. However, the continuous presence of qualified personnel may not be provided after hours. I understand that animals not picked up within the time designated will be charged an additional fee. Any animal not picked up within a timely manner, without prior arrangement, will be deemed abandoned and appropriate steps will be taken. I further understand that no guarantee of successful treatment is made. All fees are to be paid at the time of release of my animal and I agree to pay all charges incurred during my pet’s treatment and care.
I agree
Name
First Last
Pet Info
Pet Name
First
Age / Birthday (If Known)
Species / Breed
Color
Microchipped?
- Yes
- No
Chip #
If not microchipped, are you interested?
- Yes
- No
Sex
- Male
- Female
Neutered/Spayed?
- Yes
- No
Additional Pet Info
Pet Name
First
Age / Birthday (If Known)
Species / Breed
Color
Microchipped?
- Yes
- No
Chip #
If not microchipped, are you interested?
- Yes
- No
Sex
- Male
- Female
Neutered/Spayed?
- Yes
- No
Authorization for Record Transfer
To ensure accurate continuation of care, please send any and all records regarding my animals, including doctor notes, lab work, and vaccine history, to Bear Creek Animal Clinic. Please email all records including doctor notes, lab work, and vaccine history to bcac1955@gmail.com. If email is not available, please fax to 541-488-4866. If you are unable to comply with this request for any reason, please contact the office at 541-488-0120.
First Last
Enter Your Name Here
Name, phone and location (if known) of previous veterinarians:

Contact Us

1955 Ashland St
Ashland, Oregon 97520

bcac1955@gmail.com
Phone: 541-488-0120
Fax: 541-488-4866

Hours:

Monday – Friday:
7:30 am – 5:00pm

After Hours Emergency?
Southern Oregon Veterinary Specialty Center Phone: 541-282-7711

New Client Form

All fees are due at the time services are rendered

Pet Info

Additional Pet Info

Authorization for Record Transfer

Contact Us

Hours:

Monday – Friday: 7:30 am – 5:00pm

Monday – Friday:
7:30 am – 5:00pm