New Client Form

Owner's Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Primary Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Do you want to receive text messages?*

YesNo

Email*

example@example.com

Add additional Owner?*

YesNo

Owner's Name

First NameLast Name

Primary Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Secondary Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

Are you any of the following?

Senior CitizenVeteranMilitaryFire or Police Department

Previous Animal Clinic's Name*

Previous Animal Clinic's Number*

Please enter a valid phone number.Format: (000) 000-0000.

Previous Vet Records - If you have not entered a previous animal clinic, please upload vet records.

Patient's Name*

Species *

Type

Sex*

FemaleMaleUnknown

Neutered/Spayed?*

YesNoUnknown

Breed

Color

Birthdate or Age

Current Glamour Shot of your baby

Is you pet on any medications?*

YesNo

Current Medications

What food does patient currently eat?*

Amount & Frequency?*

Is your pet on any dietary supplements?*

YesNo

Current Supplements

Does your pet consume table food?*

YesNo

Please provided details on the type, amount and frequency.

Is your pet primarily indoor or outdoor?*

IndoorOutdoor

Are there any other animals in the household?*

YesNo

Who are the other animals that they live with?

Rows	Name	Age	Male/Female	Neuter/Spayed	Breed	Color
Pet 1
Pet 2
Pet 3
Pet 4
Pet 5
Pet 6

Do you have your pet groomed or boarded outside of your home?*

YesNo

If so, how often?

Does the patient have any chronic illnesses/health condition?*

YesNo

Please explain

Is your pet on flea/tick preventatives?*

YesNo

How frequently?

MonthlyEvery other monthWhen I rememberI try, but I am not the best at remembering

Name of flea/tick preventatives

Is your pet on heartworm preventatives?*

YesNo

How frequently?

MonthlyEvery other monthWhen I rememberI try, but I am not the best at remembering

Name of heartworm preventatives

Does your pet have any known allergies to any medications?*

YesNo

Please provide list of medications.

Has your pet ever had a reaction to any vaccines?*

YesNo

Please list vaccines

To allow for ample time for all patients and surgical procedures, Clear Creek Forest Animal Hospital operates primarily by appointment. We request all our clients be on time for scheduled appointments and procedures. If you are 15 minutes late to your appointment you may be asked to reschedule your appointment or will be treated as a “work in” appointment. For your convenience, we offer a limited number of same day appointments for urgent care or sick patients. These tend to fill up fast, so we recommend calling first thing in the morning.

For your protection, and that of others, pets should be properly restrained by a leash or carrier upon arrival. If your pet requires special accommodations, please give us a call when you arrive so we can assist you and your pet.

If you must cancel an appointment, we ask for a 24-hour notice. For surgical appointments, we ask for a 48-hour cancellation notice. We understand that things come up and you may need to cancel with short notice, please let us know within an hour before your appointment and we will do our best to reschedule. If you are scheduled to arrive and do not show for your appointment, we have a $60.00 no show fee.

We accept cash, debit, all credit cards, and pet insurance. We also offer Care Credit or Scratch Pay financing to help make the highest quality care accessible to all our patients.

For prescription refills or food orders, please call ahead or use our website to process these items. Please allow 24-48 hours for prescription refills. Special order items or controlled substances may require longer. You are also welcome to purchase some medications and/or food on our online pharmacy website.

I hereby authorize the veterinarian to examine, prescribe for, or treat the above described pet. I assume responsibility for all charges incurred in the care of this animal.*

I have read and agree

I understand that payment is ALWAYS DUE IN FULL at time of service. A deposit of 50% of the treatment plan may be required before treatments or hospitalization of your pet. I recognize that financial concerns should be discussed PRIOR to examination and treatment.*

I have read and agree

Does Clear Creek Forest Animal Hospital have your permission to share your pet’s image and story on our social media, website, and other forms of related media?*

YesNo

I understand that if I do not provide at least 1 hour notice of cancellation of my appointment that I will be charged a $60 no show fee.*

I have read and agree

I authorize my emergency contact (other than myself) to pursue treatment if I am unavailable. Your emergency contact must be an adult over the age of 18.*

I have read and agree

Emergency Contact Name*

First NameLast Name

Emergency Contact Phone*

Please enter a valid phone number.Format: (000) 000-0000.

Signature of Parent *

Date*

Date

New Client Form

Pet Health History

Diet and Environment

Patient History

Office Policies