Client Information Sheet
Owner’s Name
Owner’s Street Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Preferred phone
Cell
Home
Work
Cell
Home
Work
Secondary phone
Cell
Home
Work
Cell
Home
Work
Would you like to receive health & appointment reminders via TEXT?
Yes
No
Email
example@example.com
DOB
-
Month
-
Day
Year
Date
Preferred Method of Contact
Co-Owner’s Name
Co-Owner’s Street Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Preferred phone
Cell
Home
Work
Cell
Home
Work
Secondary phone
Cell
Home
Work
Cell
Home
Work
How did you hear about us?
I give permission to University Veterinary Hospital & Diagnostic Center to share pictures and stories of me and my pet(s) on their website and in social media.
Yes
No
I give permission to University Veterinary Hospital & Diagnostic Center to share your pet’s records with others such as specialists, kennels or other veterinarians.
Yes
No
I certify that I am the owner of the animals listed below or am duly authorized to act on behalf of the owner. To the best of my knowledge, the above information is correct. I understand and agree that
full payment is due at the time of service/discharge.
We accept cash, Visa, MasterCard, Discover, American Express, Care Credit, Debit Cards, Cash & Checks
Please give us
24 hours notice of cancellation
of your appointment so we may offer the time to another client.
For pets brought in by unaccompanied minors, no-emergency treatment will be denied unless payment arrangements have been pre-authorized with our staff.
I have read, understand and agree to the above financial policy
Owner/Responsible Party
Co-Owner/Responsible Party
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Patient Information
Patient #1
Species
Dog
Cat
Name
Breed
DOB or approximate age
-
Month
-
Day
Year
Date
Color
Sex
Male
Female
Male Neutered
Female Spayed
Previous or existing medical condition
Previous Veterinarian
May we contact your previous veterinarian for medical records?
Yes
No
Patient #2
Species
Dog
Cat
Name
Breed
DOB or approximate age
-
Month
-
Day
Year
Date
Color
Sex
Male
Female
Male Neutered
Female Spayed
Previous or existing medical condition
Previous Veterinarian
May we contact your previous veterinarian for medical records?
Yes
No
Patient #3
Species
Dog
Cat
Name
Breed
DOB or approximate age
-
Month
-
Day
Year
Date
Color
Sex
Male
Female
Male Neutered
Female Spayed
Previous or existing medical condition
Previous Veterinarian
May we contact your previous veterinarian for medical records?
Yes
No
Submit
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