New Customer Registration Form

New Client Form:
Owner's Name *

Prefix First Name Last Name Suffix
Partner/Other Name

Prefix First Name Last Name Suffix
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Primary Phone Number *

Area Code Phone Number
Cell Phone Number *

Area Code Phone Number
Work Phone Number *

Area Code Phone Number
E-mail
Employer's Name
Partner/Other's Employer's Name
EMERGENCY CONTACT

First Name Last Name
EMERGENCY CONTACT PHONE NUMBER

Area Code Phone Number
We will gladly prepare a written estimate if you desire. Please ask the technician or doctor.

PROFESSIONAL FEES ARE DUE AT THE TIME SERVICES ARE RENDERED UNLESS OTHER ARRANGEMENTS HAVE BEEN MADE.
Payment Terms Desires *
For more information on Care credit please ask.
Driver's License # *
Signature *

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Do you currently have pet insurance

Yes No
How did you hear about us? *
Individual name /Other
So that we are better able to suit your individual needs, which do you feel most applies to you?
Please check one:

I feel my pet is another member of our family I feel my pet is just a pet
Please check one:

I want the best medical care available for my pet. Please recommend anything that you feel is necessary for good health. I want good medical care for my pet, but there is a limit to what I am able to have done.
Please check one:

I want to learn as much as I can about pet health care. Please explain in detail what has been done for my pet or what is needed. I would prefer you just summarize what has been done for my pet or what is needed. I want my pet healthy, but don't need to know what has been done.
Please check one:

I prefer to be present when my pet is examined and treated. I would rather not see pet examined and treated.
PET MEDICAL HISTORY

Please complete all information for each pet *

Pet #1

Pet #2

Pet #3

Name

Species (cat, dog, other)

Breed

Description

Date of Birth

Sex

Altered or Spayed

Length of time owned

Diet (kind of food)

Type of Grooming Products

Hours Spent outside each day

VACCINATIONS

Distemper Combination

Rabies

Lyme

Bordetella

Heartworm Test

Feline Leukemia

Fecal Exam

Prior Illness

Prior Surgery/Dentals

Pet Origin:

Humane Society Friend Pet Shop Stray Kennel Individual Advertisement
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