New Client Form

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? *

Yes No
When is your pet's scheduled appointment? *
Client's Name *

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Cell / Mobile - Phone Number *

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? *

Yes No
Home - Phone Number

Area Code Phone Number
Email *
example@example.com
Secondary Contact - (Spouse, Family Member, Friend, Emergency Contact, etc) *

First Name Last Name
Relationship to Client *
Spouse, Family Member, Friend, etc
Secondary Contact - Phone Number *

Area Code Phone Number
Client's Date of Birth *
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? *

Yes No
How did you hear about our clinic? *

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 *
Type of Pet *

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 *
(Date and Type of last vaccinations)
Please select any symptoms that you have noticed with your pet *

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 *
(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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New Client Form

Pet Health History

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.