Heart Dog Icon

Become a New Client at Broad Ripple Animal Clinic

Completing this form does not guarantee an appointment, but our team will review your submission and contact you as soon as possible regarding availability. Thank you for your understanding and interest in our hospital!

New Client Form
Pet Owner's Name
Pet Owner's Name
First
Last
Spouse/Other Name
Spouse/Other Name
First
Last
Address
Address
City
State/Province
Zip/Postal
Which phone number should be used as your primary contact should we need to reach you?
How did you find out about us?
I authorize Broad Ripple Animal Clinic to take photos of my pet(s) to post to various social media (Facebook, Twitter, etc.).

Pet Information

plus1 Add another pet minus1 Remove a pet
Are you transferring from another veterinary hospital

Hospital Address
Hospital Address
City
State/Province
Zip/Postal

Maximum file size: 52.43MB

Maximum file size: 52.43MB

By clicking "SUBMIT", I, the undersigned owner or agent of the owner, am responsible for seeking veterinary care for the pet identified above and certify that I am eighteen years or over. I agree that after consultation with me, the hospital's doctors may prescribe medication to treat, hospitalize, sedate, anesthetize, or perform surgery on my pet.

I understand that an estimate of the fees for veterinary services will be provided to me at my request and that I am encouraged to discuss all fees related to it before services are rendered and during my pet's ongoing medical treatment. I agree to assume financial responsibility for all fees and will provide payment via cash, credit card, check or Care Credit at the time services are performed.