New Client Information Form

New Client Information Form

Welcome to our practice!
Text us: 844-430-0165 Phone: 805-493-5540 Email: reception@ah-to.com
Today's Date*

MonthDay Year
Date
Owner's Name*

First Name Last Name
Owner's Primary Cell Phone Number *

Area Code Phone Number
Spouse/Partner Name

First Name Last Name
Spouse/Partner Cell Phone Number

Area Code Phone Number
Address*

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
E-mail*
example@example.com
Pet Details

Tell us more about your family member:
I am making an appointment for my*

DogCat
Name of my Pet*
Breed*
ex: If you are not sure of exact breed just put best guess
Coat color*
Pet's Age*
Please specify weeks, months or years
Birthdate

MonthDay Year
If you know the exact birthdate please enter it here
Sex*

MaleFemale
Is your pet Spayed or Neutered?*

YesNoUnsure
Please list any current medical conditions, prior surgeries or allergic reactions
ex: bee sting allergy, diabetes, etc.
Please list any previous veterinary clinics where your pet has received care or vaccinations *
If no previous vet clinic, write "none" in box
List any current medications and flea, tick or heartworm prevention:
Ex: bravecto, Simparico Trío, Heartgard
What brand of food does your pet eat?
How did you hear about us?
We love to post cute photos of our patients on social media! Please choose:

Sure! You can post a pic of my adorable pet.My pet is shy- no photos please
Pet records and vaccine paperwork from a shelter, rescue or breeder should be sent to us prior to your appointment if possible. Text: 844-430-0165 or email: reception@ah-to.com

This will allow us to prepare your chart and minimize any wait times.
If you have additional pets, please add them here. If you are done, click "next" and then click on "submit" button.
Name of Pet #2
Pet #2

DogCat
Pet #2 Sex

MaleFemale
Pet #2 is your pet Spayed or Neutered?

YesNoUnsure
Pet #2 Breed
ex: If you are not sure of exact breed just put best guess
Pet #2 Coat Color
Pet #2 Age
Please specify months or years

Pet #2 Birthdate

MonthDay Year
If you know the exact birthdate please enter it here
For Pet #2: Please list any current medical conditions, medications, prior surgeries or allergic reactions
ex: bee sting allergy, diabetes, etc.
Name of Pet #3
Pet #3

CatDog
Pet #3 Sex

MaleFemaleMale/NeuteredFemale/Spayed
Pet #3 Breed
ex: If you are not sure of exact breed just put best guess
Pet #3 Coat Color
Pet #3 Age
Please specify months or years
Pet #3 Birthdate

MonthDay Year
If you know the exact birthdate please enter it here
Pet #3 Sex

MaleFemale
Pet #3 Spayed or Neutered

YesNoUnsure
For Pet #3: Please list any current medical conditions, medications, prior surgeries or allergic reactions
ex: bee sting allergy, diabetes, etc.
Thank you for your kindness and patience while our dedicated team works hard to provide the best medical care for your pet!

I understand that payment is due at the time services are rendered.
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