New Patient and Client Information
Thank you for choosing Friendswood Animal Clinic for your pet's medical needs. We know your pet's health is important to you. It's important to us too! We will work very hard to ensure your pet is respected and kept safe while in our care and we thank you for trusting us to care for them. Please take a few moments to fill out this form completely.
Owner Information
Owner's Name
*
First Name
Last Name
Co-owner's Name
First Name
Last Name
Primary Contact Number
*
-
Area Code
Phone Number
Primary Contact Number
*
Cell Phone
Landline
Secondary Contact Number
-
Area Code
Phone Number
Secondary Contact Number
Cell Phone
Landline
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Owner's Drivers License Number
*
Owner's Date of Birth
*
-
Month
-
Day
Year
Date
Owner's Employer
Owner's Work Number
-
Area Code
Phone Number
Co-owner's Employer
Co-Owner's Work Number
-
Area Code
Phone Number
Do you have a preferred Doctor you would like to see?
*
Dr. Donna Coleman
Dr. Joanne Murphey
Dr. Brent Melloy
Dr. Megan Lowery
Dr. Tiarra Spencer
No Preference
How did you hear about Friendswood Animal Clinic?
*
Patient Information
Patient #1's Name
*
Dog or Cat
*
Dog
Cat
Date of Birth or approximate age
*
Sex
*
Male - Neutered
Male - Not neutered
Female - Spayed
Female - Not spayed
Unknown Sex
Breed
*
Mixed or unknown is acceptable
Color
*
Any prior illnesses or surgical history we should know about?
*
Please send previous vet history to friendswood@nva.com or fax 281-482-5001.
Any known DRUG ALLERGY or VACCINE REACTIONS we should know about?
*
Please send previous vet history to friendswood@nva.com or fax 281-482-5001.
Do you have another pet to add?
*
Yes
No
Patient #2's Name
*
Dog or Cat
*
Dog
Cat
Date of Birth or approximate age
*
Sex
*
Male - Neutered
Male - Not neutered
Female - Spayed
Female - Not spayed
Unknown Sex
Breed
*
Mixed or unknown is acceptable
Color
*
Any prior illnesses or surgical history we should know about?
*
Please send previous vet history to friendswood@nva.com or fax 281-482-5001.
Any known DRUG ALLERGY or VACCINE REACTIONS we should know about?
*
Please send previous vet history to friendswood@nva.com or fax 281-482-5001.
Do you have another pet to add?
*
Yes
No
Patient #3's Name
*
Dog or Cat
*
Dog
Cat
Date of Birth or approximate age
*
Sex
*
Male - Neutered
Male - Not neutered
Female - Spayed
Female - Not spayed
Unknown Sex
Breed
*
Mixed or unknown is acceptable
Color
*
Any prior illnesses or surgical history we should know about?
*
Please send previous vet history to friendswood@nva.com or fax 281-482-5001.
Any known DRUG ALLERGY or VACCINE REACTIONS we should know about?
*
Please send previous vet history to friendswood@nva.com or fax 281-482-5001.
Authorization
WITH MY SIGNATURE, I HEREBY AUTHORIZE THE VETERINARIAN TO EXAMINE, PRESCRIBE FOR, AND/OR TREAT MY PET(S). I ASSUME FULL RESPONSIBILITY FOR ALL CHARGES INCURRED FOR THE CARE OF ALL MY PETS ON MY FILE. I ALSO UNDERSTAND THAT THESE CHARGES WILL BE PAID AT THE TIME OF RELEASE AND THAT A DEPOSIT MAY BE REQUIRED FOR SURGICAL TREATMENT OR HOSPITALIZATION.
Signature
*
Date of Signature
*
/
Month
/
Day
Year
Date
Method of Payment
*
Visa
Mastercard
American Express
Discover
Check
Care Credit
Cash
Social Media Photo Release Authorization
Will you allow us to take photos of your pet to use on our social media?
*
Yes
No
I authorize and grant Friendswood Animal Clnic to take photos of my pet regarding my experiences with them.
I grant Friendswood Animal Clinic to use my pet's photos on Facebook, Twitter, Instagram and other social media platforms.
I allow Friendswood Animal Clinic to edit, alter, copy or distribute the photos for social media advertising and marketing.
I agree that the photos belong to Friendswood Animal Clinic.
I understand that I will not receive any monetary compensation.
Signature
*
Date
*
-
Month
-
Day
Year
Date
Submit
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