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 *

Clear
Do you currently have pet insurance

Yes No
How did you hear about us? *
If referred by someone name of Individual so we can thank them /Other
Do you have a scheduled appointment? *

Yes No, Please call me to schedule one.
If Yes what date is your appointment?
example: 01/01/21
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
Should be Empty:

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New Client Form: