New Client Form

Please complete the following form so we can get to know you and your pet better!
Date:

MonthDayYear
Today's Date
Owner's First & Last Name:
Spouse/Partner's First & Last Name:
Address - Street Address/City/State/Zip Code:
Home Phone #:
Cell Phone #:
Work Phone #:
Spouse Cell Ph#:
Spouses Work Ph#:
Email:
example@example.com
Driver's License #:
Employer:
Spouses Employer:
Pet's Name:
Species

DogCatAvianReptilePocket Pet
Breed:
Sex

MaleFemale
Color:
Date of Birth/Age
Spayed or Neutered

YESNO
Pet Microchip Number:
Where was your pet obtained?:
Is your pet current on vaccinations? Yes No
We will ask for a copy of your pet's medical record to ensure our records are complete and up-to-date. May we contact your previous veterinarian's office for medical records on the pet listed above

YesNo
If "YES" please include the clinic name and phone #: Phone Number Clinic Name
Dog Distemper Group Vaccine (date given)

MonthDayYear
Date
Dog Leptospirosis Vaccine (date given)

MonthDayYear
Date
Dog Lyme Vaccine (date given)

MonthDayYear
Date
Dog Bordetella Vaccine (date given)

MonthDayYear
Date
Dog/Cat Rabies Vaccine (date given)

MonthDayYear
Date
Cat Distemper Vaccine (date given)

MonthDayYear
Date
Cat Leukemia Vaccine (date given)

MonthDayYear
Date
Does your pet have any chronic health problems we should know about? (i.e. Kidney disease, heart conditions, arthritis, diabetes, etc.)
Has your pet ever had an allergic reaction to drugs or vaccines? Please describe
Is your pet currently on medication or a special diet? If yes, please describe
How did you hear about Northern Michigan Veterinary Hospital? Check all that apply.

Google SearchSocial MediaYellow PagesVeterinary ReferralFriend or FamilySign by the RoadOther
If you answered Friend or Family, whom shall we thank? We will be sending that awesome person a "Thank You" note with a $10 discount on their pets next service!
Payment is required at time of service. My preferred method of payment is.

CashCheckCredit Card
By signing I agree that the information I have provided is accurate. I am also assuming all responsibility for the fees incurred for the care and treatment of the above listed pet.
Signature:

Clear
Date:

MonthDayYear
Date
Should be Empty: