New Client Information Form:
Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone Number
-
Area Code
Phone Number
Cell Phone Number
-
Area Code
Phone Number
E-mail - If providing an email address reminders will be sent via email and text.
example@example.com
Spouse Name
First Name
Last Name
Spouse Phone Number
-
Area Code
Phone Number
Payment is required at the time of service. For your convenience, we accept American Express, Care Credit, Discover, MasterCard, Visa, Cash, or Check (with a valid driver’s license).
License # (if paying with check):
Owner Authorization and Consent: I hereby authorize the veterinarian to examine, prescribe for, and/or treat the animal(s) described below and any other pets I may bring for treatment at a later date. I understand that if surgery is performed some degree of risk is inevitable, and it is not possible for the hospital or its staff to guarantee a successful outcome of any medical procedure. I assume responsibility for all charges incurred in the care of this animal. I also understand that all professional fees are due at the time services are rendered.
I agree
I do not agree
Client or Authorized Party Signature
Date
.
Month
.
Day
Year
Date
Pet Name
Age or Date of Birth
Species
Canine
Feline
Other
Breed and Color:
Gender
Female
Male
Spayed or Neutered
Yes
No
Unsure
Does your pet have allergies?
Yes
No
Unsure
Has your pet ever had a reaction to any medications or vaccines?
Yes
No
Unsure
If yes, to what?
List any behavior problems we should be aware of:
Previous Veterinary Clinic
Previous Veterinary Clinic's Phone Number
-
Area Code
Phone Number
Do you authorize Family Pet Animal Hospital to obtain medical records on this and/or other pets within the household?
Yes
No
Unsure
Additional Pet
Pet Name
Age or Date of Birth
Species
Canine
Feline
Other
Breed and Color:
Gender
Female
Male
Spayed or Neutered
Yes
No
Unsure
Does your pet have allergies?
Yes
No
Unsure
Has your pet ever had a reaction to any medications or vaccines?
Yes
No
Unsure
If yes, to what?
List any behavior problems we should be aware of:
Previous Veterinary Clinic
Previous Veterinary Clinic's Phone Number
-
Area Code
Phone Number
Do you authorize Family Pet Animal Hospital to obtain medical records on this and/or other pets within the household?
Yes
No
Unsure
Has your pet ever had a reaction to any medications or vaccines?
Yes
No
Unsure
Submit
Should be Empty: