Sunshine AH - New Client Form

1
Client Name
Partner Name
Address
2
Home Phone Number
Cell Phone Number
Partner Phone Number
3
E-mail Address* This field is required.
example@example.com
4
Pet #1
Pet Name
Age
Birth Date
Species
Breed
Color
Please Select
Please Select
Male
Female
Sex
Please Select
Please Select
Spayed
Neutered
Spayed/Neutered
5
Allergies/Medical Concerns
6
Do you want to add another pet information?
YESNO
7
Pet #2
Pet Name
Age
Birth Date
Species
Breed
Color
Please Select
Please Select
Male
Female
Sex
Please Select
Please Select
Spayed
Neutered
Spayed/Neutered
8
Allergies/Medical Concerns
9
Who can we contact to obtain previous medical/vaccine history?
10
How did you hear about us?
11
Do we have permission to send your pets records in the event they are requested by another facility?
12
Help us customize your visit
13
Are there any peanut allergies in your household?
Yes
No
14
Can we post photos of your pet on our website/social media?
Yes
No
15
Is your pet aggressive towards other animals?
Yes
No
16
Has your pet ever shown aggression towards people during a vet visit?
Yes
No
17
On a scale of 1-10, 1 being not anxious at all, how anxious is your pet about coming to the vet?
1
2
3
4
5
6
7
8
9
10
18
Do you need an ADA compliant entrance or help getting into the building?
Yes
No
19
Does your pet have trouble with slippery floors?
Yes
No
20
What is your preferred communication method?* This field is required.
E-mail
Phone
Text
21
Do you prefer to check out at the front desk or in the exam room?
22
Does your pet have any food allergies? If so, what?
23
Does your pet have a favorite treat? If so, what?
24
I understand that I am responsible for all professional and hospital fees, including fees for medications and diagnostic procedures, and agree to pay, in full, for all services at the time they are rendered. This responsibility continues in the event my pet fails to recover, dies, or is euthanized. I am encouraged to discuss all fees attendant to the care of my animal before services are rendered, and to request a written estimate of involved fees if one has not been provided to me. Any verbal or written estimate of charges or fees is only a best approximation, and the final charges may be less than or greater than this amount. I agree to pay, upon request, a deposit of 50% of the estimated fees for hospitalization or admittance for a surgical or dental procedure, and to pay for the balance of all services rendered on a cash, credit card or check basis upon discharge.
25
Signature* This field is required.
Clear
26
Date
Date
Year
Month
Day
Should be Empty: