DogDoctor@aol.com
Phone: 330-757-8868
6609 Clingan Rd.
Poland, OH 44154 
Copyright 2006 Poland Veterinary Centre 


  Poland Veterinary Centre
    We care for your pets as if they are ours
Welcome to Our Site

New Client Check In

If you would like your pet to become a patient of our hospital, please take a moment to complete and submit the following form. This will help to expedite your appointment.

Thank you for your cooporation in letting us assist you.


 

Form - New Client Form

Name (required)
First Name (required)
Last Name (required)
E-Mail Address (required) :
Address (required)
Street Address (required)
City (required)
State/Province (required)
Zip/Postal Code (required)
,
Phone #1 (required)
Phone TypePhone Number (required)
Phone #2 (required)
Phone TypePhone Number (required)
General Information
Pets Name (required)

Please Select Pet Species (required) :
Are your pets vaccines current?
Would you like us to call to make an appointment?
Special request or conditions?

What has prompted your first visit?

Previous medical records (choose one) (required) :
Please list any additional pets here:


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