NEW CLIENT FORM

Name*

First NameLast Name

Cell:*

Primary Email:*

example@example.com

Address:*

City:*

State:*

Zip:*

Spouse or Alternate Contact:

Relationship:

Spouse/ Alternate Contact Phone:

Name:*

Cat or Dog*

CatDogOther

Breed or Best Guess:*

Color:*

Sex*

MaleFemale

Is your pet Spayed or Neutered?*

YesNo

Does your pet have a microchip?

YesNo

Birthday or best guess for birthday

In order to best manage your pet's medical care, it is important to have a full medical history. Please allow us to contact your previous veterinarian to obtain records by providing their information below:

We would love to thank the person(s) responsible for your referral, or how you heard of us:*

SCRIBBLEVET CONSENT AND RELEASEOur veterinary services utilize ScribbleVet, a tool from Kairo Care, Inc., which records your pet's appointments for improved clinical documentation. We need your consent to proceed with the recording. By signing this agreement:
1. Appointment Recording: You agree that your vet appointments may be recorded. If you don’t want to be recorded, let us know.
2. Usage Rights: You grant us permission to share these recordings internally, and any other materials you choose to provide, for the purpose of improved clinical documentation.
3. Age Confirmation & Understanding: You affirm that you are at least eighteen years old, and that you understand and accept the terms in this agreement. We are committed to providing the best care for your pet in a manner comfortable for both of you.

Full payment is due when services are rendered. WE DO NOT ALLOW BILLING OF ANY KIND. On your request, we can provide a written estimate of expected diagnostics and treatment recommendations. Surgeries, hospitalizations, and emergency services may require a deposit prior to treatment. Our staff will be happy to discuss finance options, such as Care Credit or Scratch Pay.*

I acknowledge the payment policies of Cole Veterinary Clinic.

Signature*

Date:*

Date

Cole Veterinary Clinic uses PetDesk® to manage client communications, send you reminders about upcoming appointments, patient reminders of services due, and status updates regarding your pet while they are here in our hospital. You agree that we may share your name, pet’s name, email address, address, and phone number with PetDesk to facilitate this process. Contact subscriptions may be changed at anytime by replying to notifications or through the PetDesk app. To learn more about PetDesk or their privacy policies, please visit www.PetDesk.com or download their iOS or Android mobile applications.

NEW CLIENT FORM

OWNER INFORMATION

PATIENT INFORMATION