New Client Registration Form

Full Name*

First NameLast Name

Spouse Name

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone Number*

Area CodePhone Number

Spouse Phone Number

Area CodePhone Number

E-mail *

Who may we thank for referring you?

Emergency Contact

First NameLast Name

Emergency Contact Phone Number

Area CodePhone Number

Is this person authorized to make treatment decisions if you are unreachable?

YesNo

Patient Information:

Pet Name*

Species:*

DogCatOther

Breed (if known)*

Color*

If "Cat" selected, current outdoor access status?

Indoor onlyIndoor/Outdoor UnsupervisedIndoor/Outdoor Supervised onlyOutdoor only

Age (approx. if unknown)*

Birthday (if known)

Date

Sex*

MaleFemale

Spayed/Neutered?*

YesNo

Weight

Microchip Number

Does your pet have any known allergies? If so, please list

Does your pet have any known medical conditions? If so, please list

Additional information you'd like us to know:

Primary or Previous Veterinarian

Primary/Previous Veterinarian Phone Number

Area CodePhone Number

Would you like us to contact them for your pet's previous records?

YesNo

Additional Pet (if applicable)

2nd Pet Name

2nd Pet Species

DogCatOther

2nd Pet Breed

2nd Pet Color

2nd Pet Age (approximate if unknown)

2nd Pet Birthday (if known)

Date

2nd Pet Sex

MaleFemale

2nd Pet Spayed/Neutered?

YesNo

2nd Pet Additional Info You'd Like Us To Know:

Do you already have an appointment scheduled? If so, please indicate the date below:

Date

No-Show/Cancellation Policy: You MUST cancel at least 24 hours in advance or you will be charged $50 for a veterinary appointment, $100 for a surgery appointment, or 100 PERCENT of your scheduled grooming service. We understand emergencies and unfortunate events happen and will do our best to accommodate you on a case by case basis. We send out text and email reminders, but these should not be relied on.*

I understand and agree.

Deposit Policy: Any deposit taken will reflect as credit toward your appointment balance. All deposits are refundable only if the appointment is canceled or rescheduled at least 24 hours in advance.*

I understand and agree.

COVID-19 Policy: Please do not bring your pet in if your are experiencing symptoms of corona virus or were exposed to someone who might have contracted the virus.*

I understand the above and agree.

I hereby authorize Family Pets Veterinary Care to render medical care for my pet(s) as deemed necessary by the veterinarian. I understand that no guarantee can be given to the outcome of treatments and take it as my responisibility to comprehend any risks involved. I agree to pay for the cost of all services to which I consent to by written or verbal estimate. I understand that payment is required in full before diagnostics and treatments can be initiated.

Signature*

First NameLast Name

Today's Date*

Date

New Client Form