Welcome Dr. Bednar to our Irvington Location – Starting June 19th!

317-785-3260

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New Client Form

Step 1 of 3

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Client Information

Client Name(Required)

First

Last

Spouse/Partner Name

First

Last

Address(Required)

Street Address

Address Line 2

City

State

ZIP Code

Driver's License Number

Driver's License State + Expiration Date

Cell Phone(Required)

Home Phone

Work Phone

Spouse/Partner Cell Phone

Email(Required)

May we use your pet’s name and/or photo in our social media, blog posts, and/or advertising?(Required)

yes

How did you hear about us?(Required)

Google

Yelp

Instagram

Facebook

At an event

Through another local business

From a Friend

Other

Please enter your friend's name so they may receive a referral bonus!

First

Last

Patient Information

Name of Pet(Required)

Species(Required)

cat

dog

Other

Breed(Required)

Color(s)(Required)

Birth Date or Approximate Age(Required)

Sex(Required)

male

female

Has your pet been spayed or neutered?(Required)

yes

Has your pet been microchipped?(Required)

yes

Previous Veterinarian/Clinic

Upload a photo of your pet

Accepted file types: jpg, png, jpeg, pdf, Max. file size: 50 MB.

Jpgs, pngs, or pdfs under 2MB accepted.

Do you have any other pets?(Required)

yes

Patient Information for 2nd Pet

Name of Pet(Required)

Species(Required)

cat

dog

Other

Breed(Required)

Color(s)(Required)

Birth Date or Approximate Age(Required)

Sex(Required)

male

female

Has your pet been spayed or neutered?(Required)

yes

Has your pet been microchipped?(Required)

yes

Previous Veterinarian/Clinic

Upload a photo of your 2nd pet

Accepted file types: jpg, png, jpeg, pdf, Max. file size: 50 MB.

Jpgs, pngs, or pdfs under 2MB accepted.

Do you have any other pets?(Required)

yes

Patient Information for 3rd Pet

Name of Pet(Required)

Species(Required)

cat

dog

Other

Breed(Required)

Color(s)(Required)

Birth Date or Approximate Age(Required)

Sex(Required)

male

female

Has your pet been spayed or neutered?(Required)

yes

Has your pet been microchipped?(Required)

yes

Previous Veterinarian/Clinic

Upload a photo of your 3rd pet

Accepted file types: jpg, png, jpeg, pdf, Max. file size: 50 MB.

Jpgs, pngs, or pdfs under 2MB accepted.

Do you have any other pets?(Required)

yes

Patient Information for 4th Pet

Name of Pet(Required)

Species(Required)

cat

dog

Other

Breed(Required)

Color(s)(Required)

Birth Date or Approximate Age(Required)

Sex(Required)

male

female

Has your pet been spayed or neutered?(Required)

yes

Has your pet been microchipped?(Required)

yes

Previous Veterinarian/Clinic

Upload a photo of your 4th pet

Accepted file types: jpg, png, jpeg, pdf, Max. file size: 50 MB.

Jpgs, pngs, or pdfs under 2MB accepted.

Note: If you have more than 4 pets, please fill out the form a second time and add your remaining pets.

Payment is due at time of service. Cash, check, and credit card are accepted forms of payment. All returned checks are subject to a $27.50 NSF fee. I understand City Way Animal Clinics will utilize the Marion County Bad Check Program to prosecute bad check writers to the fullest extent of the law.(Required)

I assume responsibility for all charges incurred in the care of my pet(s).

Today's Date(Required)

MM slash DD slash YYYY

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Phone

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