New Client and Patient Form

Client and Patient Information

Thank you for giving us the opportunity to care for your pet(s). So that we may become better acquainted, please complete the following:
Name *
Spouse/Co-Owner
Address *

Address

Street Address Line 2

City State

Zip
E-Mail Address *
example@example.com
Primary Phone Number *
Is your primary phone number a mobile number? *

Yes No
Work Phone Number
Employer
Spouse/Co-Owner's Cell Phone Number
Spouse/Co-Owner's Employer & Phone Number
Emergency Contact *
Emergency Contact Phone Number *
How did you become aware of our clinic? *

Web Site KMUW Google Facebook Personal Recommendation
Personal Recommendation (whom may we thank?)
May we have your permission to use your pet's photo on our social media accounts? *

Yes No

	Pet 1	Pet 2
Name
Breed
Date of Birth/Age
Color
Alleriges?
Special diet or medication(s)?
Pet Health Insurance Company?

Previous Medical Records? Previous Clinic Name and phone number: *
We offer Military and Senior Citizen discounts. Do you qualify? Military ID or Drives License will be require for verification before applying the discount. *

Military Discount (Active or Veteran) Senior Citizen (over 65) Neither
I agree to pay any costs and charges necessary for the collection of any amount not paid when due.

A full payment is required upon rendering of services. We do NOT carry open accounts.

We accept the following: Cash, Check , Visa, MasterCard, Discover, American Express, Care Credit, and Scratch Pay
Signature of owner or authorized representative: *

Clear
Date: *

Month Day Year
Date
THANK YOU for bringing your pet to our hospital. We hope you are pleased with our services and facilities. We would appreciate your letting us know how we might improve them.
404 S. Edgemoor, Bldg 100 Wichita, KS 67218
316-683-4641 www.skaervet.com
Should be Empty:

Client and Patient Information