New Client Form

New Client Form
Client Information
Primary Owner*

First NameLast Name
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
Cell Phone*
Email Address*
example@example.com
Driver's License Number
Employer and Occupation
What is your preferred method of contact?*

TextCallEmail
May we text you with lab results?*

YesNo
Do you give permission for us to post pictures/videos of your pet on our social media accounts?*

YesNo
Spouse/Co-Owner Name

First NameLast Name
Contact Number
Email Address
example@example.com
Emergency Contact

First NameLast Name
Contact Number
Relationship
Relationship
Referred by a friend? Who may we thank for this referral?
Financial Policy
Animal Family Veterinary Care Center requires payment in full for professional services when your pet is discharged from the hospital. As legal owner or responsible agent of the above animal, I certify that I have read and agree to this financial policy. I hereby assume financial responsibility for all services rendered
Choice of payment (Select all that apply)*

Credit/DebitCash/CheckCare Credit - ApplyToday https://www.carecredit.com/go/324RFBScratch Pay - Apply Today Text PLAN to 97364 or scratchpay.com
Signature of owner/agent*

Clear

Pet Information
Pet's Name*
Date of Birth*

MonthDayYear
Species*
Breed (Dog)
Breed (Cat)
Breed (Small Mammal)
Breed (Reptile)
"Other" Breed (Dog)
If your dog's breed isn't on the dropdown list, please write it here.
"Other" Breed (Cat)
If your cat's breed isn't on the dropdown list, please write it here.
"Other" Breed (Small Mammal)
If your small mammal's breed isn't on the dropdown list, please write it here.
"Other" Breed (Reptile)
If your reptile's breed isn't on the dropdown list, please write it here.
Breed
Does your pet have an I.D. Microchip*

YesNo
How would you describe your pet's temperament?

Outgoing/SocialNeutralShyAggressive
How many hours a day does your pet spend outside?*

01-33-66-1212-24
What concerns do you have about your pet? (select all that apply)*

Bad breathCoughingEar problemsEye problemsWeight gain/lossNot eatingVomitingDiarrheaAccidents in the houseBarkingItching/scratchingSores/woundsClawing/diggingLamenessProblems getting upBehavior changesSeparation anxietyAggressionNo concernsOther
If you selected any of the concerns above, please explain in detail*
Please list any prior illnesses or surgeries*
What food are you currently feeding your pet?*
Does your pet take any prescribed or over the counter medication? If yes, please list:*
Has your pet ever been prescribed anxiety medication to help with visits before?*

YesNo
If yes, what were they and what were the end results?
Do you currently have health insurance for your pet?*

YesNo
Are you interested in learning more about pet health insurance?*

YesNo

Comfort and Temperament
How would you describe your pet's reaction when going to the vet?*

Eager and excitedSubduedReluctantNervous/AnxiousOther
Are there certain things you and/or your pet do not like while at the vet?*

Being weighedExam tableHaving a procedure doneWalking into and through the clinicBeing handled by staffNo concerns
How would you describe your pet around other animals, such as in a waiting area?*

Dog and/or cat aggressiveNervous/anxiousHides/tremblesNo issues
What are your pet's favorite treats? (You're always more than welcome to bring some treats from home.)*
What kind of toys does your pet like? (You're always more than welcome to bring their favorite toy along with them.)*
How and where does your pet travel in the vehicle?*

CarrierSeatbeltLoose
Is your pet reluctant when getting into the carrier or vehicle?*

YesNo
Have you seen any of these behaviors while in the car?*

Vocal/whiningRestless/pacingPanting/droolingHiding/tremblingNone
Does your pet experience any nausea while traveling?*

YesNoNot sure
Which is most important to you?

Bringing my pet to the vet as few times a year as possibleSpreading payments out over the year
What else should we be aware of about your pet?*
**If your pet has experienced any vomiting or diarrhea recently** **please bring in a fresh stool sample**
Thank you! We look forward to seeing you at your appointment.
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