New Client Establishment
Welcome! We look forward to caring for your pets.
Owner's Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Cell Phone
*
-
Area Code
Phone Number
Home Phone
-
Area Code
Phone Number
Work Phone
-
Area Code
Phone Number
Email Address
example@example.com
Would you like a co-owner on your account?
*
Yes
No
Co-Owner's Name
Relationship to co-owner
Spouse
Significant other
Family
Friend
Other
Co-owner Phone Number
-
Area Code
Phone Number
How did you find us?
*
Website
Internet search
Friend or family
Other veterinary office or business
Other
Which website?
*
What search term did you use?
*
Please provide us with their name so we can send them a thank you with clinic credit!
*
Name of veterinary office or business
*
Please explain
*
Pet's Name
*
Birth date or age
*
Species
*
Cat
Dog
Other
Breed(s)
*
Color(s) / Marking(s)
*
Sex
*
Female
Male
Unknown
Spayed or neutered
*
Yes
No
Uncertain
Would you like more information on spaying or neutering your pet?
*
Yes
No - My pet is scheduled or will be scheduled to be spayed / neutered at another facility
No - I do not intend on spaying / neutering my pet and am aware of the health and behavior risks
Does your pet have any medical conditions we should be aware of?
e.g. diabetic, history of seizures, allergies
Anything you'd like us to know to make your pet's visit stress-free?
e.g. prefers females, doesn't like feet touched, owner protective, does not do well around dogs, etc.
It's important for us to obtain your pet's full medical history prior. We are happy to reach out to their previous veterinary office(s).
Please provide us with the following:
Previous practice(s) name
City and state
Previous practice phone number (if available)
-
Area Code
Phone Number
Pet first and last name (if different than names provided)
Are there other pets in your household you'd like us to request history for? If yes, please list name(s) and species below:
For pets adopted from shelters/rescue organizations or new puppy/kitten vaccine info from breeders, you can upload a copy of their medical history here:
Browse Files
If you don't currently have access to this, please be sure to send to the office at least 24 hours prior to your pet's appointment
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Privacy and Medical Records release
Section 801.353 of the Texas Veterinary Licensing Act protects your privacy by prohibiting disclosure of your pet(s) health care records (including rabies and other immunizations) without our specific authorization.
I give Northwest Veterinary Hospital permission to release information concerning the veterinary care for my pet(s):
*
Yes
No
I give Northwest Veterinary Hospital permission to use my pet(s) names and pictures for display, public relations and marketing.
*
Yes
No
By signing this form, I acknowledge I have read and agree to the missed appointment policy
Signature
*
Print Name
*
Submit
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