Grooming New Client Registration Form

Full Name*

First NameLast Name

Spouse Name

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone Number*

Area CodePhone Number

Spouse Phone Number

Area CodePhone Number

E-mail *

Emergency Contact

First NameLast Name

Emergency Contact Phone Number

Area CodePhone Number

Is this person authorized to make treatment decisions if you are unreachable?

YesNo

Who may we thank for referring you?

Patient Information:

Pet Name:*

Species:*

DogCatOther

Breed (if known):*

Color:*

Age (approx. if unknown):*

Birthday (if known):

Date

Sex:*

MaleFemale

Spayed/Neutered?*

YesNo

Weight:

Microchip Number:

Does your pet have any known allergies? If so, please list

Does your pet have any known medical conditions? If so, please list

Primary or Previous Veterinarian

Primary/Previous Veterinarian Phone Number

Area CodePhone Number

Additional Pet (if applicable):

2nd Pet Name:

2nd Pet Species:

DogCatOther

2nd Pet Breed (if known):

2nd Pet Color:

2nd Pet Age (approx. if unknown):

2nd Pet Birthday (if known):

Date

2nd Pet Sex:

MaleFemale

2nd Pet Spayed/Neutered?

YesNo

2nd Pet Weight:

2nd Pet Microchip Number:

2nd Pet Allergies or Known Medical Conditions:

No-Show/Cancellation Policy: You MUST cancel within 24 hours or you will be charged $50 for a veterinary appointment, $100 for a surgery appointment, or 100 PERCENT of your scheduled grooming service. We understand emergencies and unfortunate events happen and will do our best to accommodate you on a case by case basis. We send out text and email reminders, but these should not be relied on.*

I have read the above and agree.

COVID-19 Policy: Please do not bring your pet in if your are experiencing symptoms of coronavirus or were exposed to someone who might have contracted the virus. Our office is closed to the public. We ask that you wear a mask when interacting with our staff and doctors.*

I have read the above and agree

I hereby authorize Family Pets Veterinary Care to render medical care for my pet(s) as deemed necessary by the veterinarian. I understand that no guarantee can be given to the outcome of treatments and take it as my responisibility to comprehend any risks involved. I agree to pay for the cost of all services to which I consent to by written or verbal estimate. I understand that payment is required in full before diagnostics and treatments can be initiated.

Signature*

First NameLast Name

Today's Date*

Date

Grooming New Client Form