New Client

Community Veterinary Hospital

1631 West Bay Drive
Largo, FL 33770

(727)585-2007

www.communityveterinaryhospital.com

Current Client Appointment Form

If you would like to make an appointment, you can assist us to expedite your check in by submitting this form.

Thank you for your cooporation in letting us assist you.

Current Client Appointment Form

Name (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)

Type of Pet (required) :

Would you like us to contact you to make an appointment

Has your pet been seen in our clinic in the last year?

Please tell us the reason for your pets visit

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 Community Veterinary Hospital 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 Community Veterinary Hospital'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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Dr. Lester Mandelker is the owner and director of Community Veterinary Hospital located in the Clearwater and Largo area of Pinellas County in Florida. He also runs The Paradise Pet Motel located on the premises. Dr. Mandelker is the only board Certified Veterinary for both Dogs and Cats in the Belleair, Clearwater, Largo and Seminole areas of Pinellas County Florida. He has practiced for over 35 years and has been recognized twice among the nations top veterinarians. He practices on all dogs, cats and exotic pets.