New Client

Islands Animal Clinic
1530 West Elliot Road
Gilbert, AZ 85233
(480) 892-3558

No Description
Islands Animal Clinic
1530 W. Elliot Rd.
Gilbert, AZ 85233
(480) 892-3558

                                                                                         Refer a client to us and get $25
                                                                                            Click here.

Welcome to Our Site

Welcome to Islands Animal Clinic

1530 W. Elliot Road Gilbert, AZ 85233

(480) 892-3558

Dr. Michael Retford, DVM

Dr. Tracey Jaffe, DVM

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

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 Islands 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 Islands 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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