New Client Form
Thank you for choosing Animal Tracks Veterinary Hospital. Please complete this form so that we can accurately enter your information into our files. Information provided on this form is and will always be strictly confidential.
Does your pet have an appointment scheduled already?
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Yes
No
When is your pet's scheduled appointment?
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Client's Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Cell / Mobile - Phone Number
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-
Area Code
Phone Number
Animal Tracks Veterinary Hospital may use text reminders to send out appointment reminders and pet vaccination reminders. May we use this number to text?
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Yes
No
Home - Phone Number
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Area Code
Phone Number
Email
*
example@example.com
Secondary Contact - (Spouse, Family Member, Friend, Emergency Contact, etc)
*
First Name
Last Name
Relationship to Client
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Spouse, Family Member, Friend, etc
Secondary Contact - Phone Number
*
-
Area Code
Phone Number
Client's Date of Birth
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Client's Driver's License Number
*
Number and State Issued
Client's Employer
Client's Work Phone Number
*
-
Area Code
Phone Number
If we take a picture of your pet while here today, may we use the picture on social media?
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Yes
No
How did you hear about our clinic?
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Already a client - updating information
Drove by
Referral
Social Media - Facebook, Instagram, etc
If you were referred, who may we thank for referring you?
First and Last Name
Reason for Visit
*
Pet Health History
Name of Pet
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Type of Pet
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Dog
Cat
Pet's Birthdate
*
-
Month
-
Day
Year
Date
Breed
*
Color
*
Sex
*
Male - Intact
Male - Neutered
Female - Intact
Female - Spayed
Vaccination History - Please include where vaccinations were administered
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(Date and Type of last vaccinations)
Please select any symptoms that you have noticed with your pet
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Behavior problems
Bleeding Gums
Breathing Problems
Coughing
Diarrhea
Eyes Bulging or Bloodshot
Gagging
Lack of Appetite
Limping
Loss of Balance
Scooting
Scratching
Seems depressed
Shaking Head
Sneezing
Thirst and/or Urination Increased
Vomiting
Weakness
Pet's Current Medications
*
(Medications, vitamins, and supplements)
Describe Your Pet's Diet
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(Type of food. How much do you feed and how often.)
We pledge to do our very best to care for your pet's health needs. In return, we ask that you accept the responsibility for charges incurred during the treatment of your pet(s) and understand that payment is due at the time of services.
I hereby authorize the veterinarian to examine, prescribe for, or treat the above described pet. I assume responsibility for all charges incurred in the care of this animal. I also understand that these charges will be paid at the time of release and that a deposit may be required for treatment.
Signature
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Submit
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