New Client Form (Custom PDF update 3.3.21)

Download our app before your visit! Once you submit this form and your chart is made in our system you will be able to create an account using the email address you provide below.

Date of Appointment

Date

Time of Appointment*

Hour Minutes

AM/PM Option

Primary Contact Name*

First NameLast Name

Primary Contact Cell Number*

Please enter a valid phone number.

Primary Contact Home Number

Please enter a valid phone number.

Secondary Contact Name

First NameLast Name

Secondary Contact Number

Please enter a valid phone number.

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email*

example@example.com

How did you hear about us?*

If referred by a current client, please tell us who so we can say thank you!

We know there are a lot of veterinary options for you and we are so glad you chose us! We would love to know why you chose us:*

Pet's Name (1)*

Species (1)*

CanineFelineOther

Breed (1)*

Color (1)*

Sex (1)*

Spayed FemaleFemaleNeutered MaleMale

Age/ Date of Birth (1)*

Microchip Number (1)*

Dates of the most recent vaccinations (1)*

Any previous health issues? (1)*

Name and contact of your previous veterinarian? (1)*

Pet's Name (2)

Species (2)

CanineFelineOther

Sex (2)

Spayed FemaleFemaleNeutered MaleMale

Breed (2)

Color (2)

Age/ Date of Birth (2)

Microchip Number (2)

Dates of the most recent vaccinations (2)

Any previous health issues? (2)

Name and contact of your previous veterinarian? (2)

We love social media! We would like your consent to share your pet's image on our social media pages and website. Your full name and personal information will never be used.*

Yes, please make my pet a star!No thank you, my pet is shy

If you have any digital medical records please attach them here. If you have paper records you could always take well lit photos of them with your phone and upload those as well!

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Our veterinary team is committed to our values of Empathy, Compassion, Understanding and Open Communication. We ask that you partner with us and share in these values. We will not tolerate yelling, swearing or any type of abuse to our team. If something is not right, we want to help address it, in a respectful manner.

Sincerely, The Doctors and Team at Crescenta Cañada Pet Hospital

I confirm that the above information is correct and that I am the owner or authorized agent of the patient listed above. I hereby authorize the veterinarian to examine, prescribe for and treat the above described pet. I assume responsibility for all charges incurred in the care of this animal. I understand that payment is always due in full at the time of service. I recognize that financial concerns should be discussed prior to exam and treatment. For your convenience we accept Visa, MasterCard American Express, cash and checks with proper identification. Please discuss any financial questions with the front desk.

Signature*

Clear

New Client Form

Pet #1

Pet #2