Westside Vet New Client Forms and Environmental History

New Client Form

Thank you for giving us the opportunity to care for your pet(s)!
Full Name*

First NameLast Name
Spouse/Co-Owner (please include people qualified to make medical decisions for your pets)
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Inside Jefferson City Limits? Y/N*
Phone Number*
Format: (000) 000-0000.
E-mail*
example@example.com
YesNo
How did you hear about us?*
If personal recommendation (or other source), whom may we thank?

Patient History and Lifestyle Evaluation

Please complete the following so we may best determine your pet's needs.
Pet's Name, Dog/Cat?, Age/Date of Birth?, Male/Female?, Spayed/Neutered?, Breed?, Color?
Please list additional pets and information in the box below.
Please List additional pet(s) and information below
Geographical History- Complete for ALL PETS in household.
YesNo
Where do you currently live? (Rural/ Suburb/ City) Where else has this pet lived?
YesNo
If yes, where have you taken your pet?
Household Information
Member of our familyChild's petBackyard pet
If there are other pets in the family than those listed above, what kind of pets? (include all species):
What family members live in the household with the pet? Number of infants and children (include ages): blanks. Number of adults: blank seniors: .
Where does your pet sleep? (Be as specific as possible: indoors/outdoors?; room? pet bed and location?)

New Client Form