New Client/Patient Form
How Did You Hear About Village Animal Clinic
Drove By
Yellow Pages
Internet Search
Website
Personal Recommendation (We would like to thank them)
Client Information
Name
*
First Name
Last Name
Spouse/Significant Other (person authorized to make decisions regarding your pet)
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / County
Postal / Zip Code
Primary Phone Number
*
-
Area Code
Phone Number
Secondary Phone
-
Area Code
Phone Number
Can We Text you at these Numbers?
If yes to texting. Is it to Primary Number, Seconday Number or Both
Primary email address (for us to communicate with you)_
*
example@example.com
Person Responsible for Payment
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Patient Information
Pets Name
Canine/Feline or Other
Canine
Feline
Other
Breed
Date of Birth or Age
Coat Color
Sex
Male Neutered
Male Not Neutered
Female Spayed
Female Not Spayed
Currently on Heartworm Protection
Yes
No
Currently on Flea/Tick Protection
Yes
No
Does your pet have a microchip
Yes
No
Unsure
Previous Clinic Name/Phone Number
Other Pets in Household we have not seen?
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Vaccine History(indicate month and year done)
Rabies Month and Year
Canine Distemper/Parvo Month and Year
Leptospirosis Month and Year
Bordetella Month and Year
Lymes Month and Year
Heartworm Blood Test Month and Year
Fecal (stool sample) Test Month and Year
Feline Distemper Month and Year
FELV/FIV Blood Test Month and Year
Any Known Allergies
Previous Diagnosed Conditions
Medical Records Waiver
PLEASE CHECK ONLY ONE BOX
Allmedical Information may be released to any individual or organization for all my pets registered on my account
Only vaccine history and heartworm/fecal testing may be released to any individual or organization for all my pets registered on my account. No other medical information shall be released
No medical information or any vaccination history shall be released to any individual or organization with my expressed written consent pertaining to all of my pets registered on my account
Signature
Clear
Date
-
Month
-
Day
Year
Date
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PLEASE READ AND ACCEPT OR DECLINE
Village Animal Clinic is authorized to post pictures of my pet(s) online via facebook, instagram, twitter or the Village Animal Clinic website. Only your pets first name will be used. (PLEASE CHECK ONLY ONE BOX)
Accept
Decline
Submit
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