NEW CLIENT FORM

Your Name

First NameLast Name

Spouse's Name

First NameLast Name

Address

Street Address Line 2

CityState

Zip

Cell Phone:

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

May we text your cell phone?

Secondary Phone Number

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

E mail:

example@example.com

Emergency Contact:

Emergency Contact Phone Number

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

Previous Veterinarian's Name:

Previous Veterinarian's Phone Number

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

How did you hear about Pet Vet?

If you were referred by a friend or

Name

relative what is their name and address?

Address

I'm coming in today for the following:

Please fill out your pet(s) information in the boxes below.

Rows	Patient #1	Patient #2	Patient #3	Patient #4
Pet's Name
Cat or Dog
Birthday (w/year)
Breed
Color
Sex
Microchip #
Medical Alerts
Allergies
Vaccines Last Completed
Prior Surgeries
Prior Illnesses

I grant my permission to use my pet(s) photo or video footage for social media purposes.

I hereby authorize the veterinarian to examine, prescribe for, or treat the above described pet. Only after I have agreed to the charges will I assume responsibility for all charges incurred in the care of the animal. I also understand that all professional fees are due at the time services are rendered and that billing is not an option. The information on this form is strictly confidential and is to be used only by this practice to provide care and treatment for your pet.

NOTICE TO CLIENTS REGARDING PRESCRIPTIONS

Clients have the right to request a written prescription for their pet’s medications and may choose to have prescriptions filled at the pharmacy of their choice, including outside and online pharmacies, subject to applicable federal and state laws and the existence of a valid veterinarian-client-patient relationship (VCPR).

Our clinic will provide written prescriptions upon request in accordance with professional and legal requirements. Certain medications may require:

A current examination or established VCPR
Recommended monitoring or laboratory testing
Compliance with federal and state prescribing regulations
Please note:

Prescription requests may require processing time.
Fees for examinations, consultations, or administrative services may apply where permitted by law.
Controlled substances and certain specialty medications may be subject to additional restrictions.

I agree to the above terms & conditions

Signature of Responsible Party

Date:

Date

Secondary Phone:

Emergency Contact Phone:

Cell Phone:

Previous Veterinarian's Phone Number: