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
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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
How did you hear about us?
Internet
Yellow Pages
Hospital Sign
Personal Recommendation
If personal recommendation, whom can we thank?
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
Clear
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
When was the last date of vaccination?
When was the last date heartworm prevention was administered?
Has your pet received a heartworm occult test or intestinal parasite screening in the past year?
Yes
No
Unsure
If yes, when was it performed?
Has your pet ever had a reaction to any medications or vaccines?
Yes
No
Unsure
If yes, to what?
List any major surgeries your pet has had:
List any behavior problems we should be aware of:
Current diet and treats:
Previous Veterinary Clinic
Previous Veterinary Clinic's Phone Number
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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
Submit
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