New Patient and Client Information

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.
Due to COVID-19 we are seeing patients as a "curb-side service". NO PERSONS ARE ALLOWED INTO THE BUILDING. Communications and payment will be done via telephone and a Technician will come to your car to bring your pet to and from the building. We appreciate your cooperation.
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? *
How did you hear about Friendswood Animal Clinic? *
Patient Information
Patient #1's Name *
Dog or Cat *
Date of Birth or approximate age *
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 *
Date of Birth or approximate age *
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 *
Date of Birth or approximate age *
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. I ALSO UNDERSTAND AND AGREE TO A $3.50 BILLING CHARGE AND RESPONSIBILITY FOR ANY COLLECTION CHARGES FOR A BALANCE DUE FOR ANY REASON.
Signature *

Clear
Date of Signature *

Month Day Year
Date
Method of Payment *Care Credit is NOT accepted *

Visa Mastercard American Express Discover Check 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 *

Clear
Date *

Month Day Year
Date
Should be Empty:

New Patient and Client Information

Owner Information

Patient Information

Authorization

Social Media Photo Release Authorization