New Client & Patient Information

Name: *

First Name Last Name

Secondary Name/Spouse Name: (if applicable)

First Name Last Name

Phone Number: *

Please enter a valid phone number.

Secondary Phone Number:

Please enter a valid phone number.

Email: *

example@example.com

Address: *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Drivers License Number: *

Place of Employment: *

Emergency Contact Name:

First Name Last Name

Emergency Contact Phone Number:

Please enter a valid phone number.

How did you hear about us? *

If someone referred you, please provide their name so we can send them thanks!

Date of Scheduled Appointment: *

Time of Scheduled Appointment: *

First Animal's Name: *

Date of Birth or Approximate Age: *

Species: *

Breed: *

Color: *

Gender: *

Male Female Unknown

Is your pet spayed or neutered? *

Yes No Unknown

What is the reason for your pet's visit today? *

Is your pet currently taking any medications? *

Yes No Unknown

If you answered yes, please list the medications that your pet is currently taking:

Has your pet experienced any of these symptoms within the last 5-7 days? Select ALL that apply: *

Coughing Sneezing Vomiting Diarrhea Weakness Lethargy Pain or discomfort Other None

If you selected any of the symptoms above, please describe in more detail:

Do you have previous medical records for your pet(s)? *

Yes No Not with me

You can upload files here:

Second Animal's Name (if applicable)

Date of Birth or Approximate Age:

Species:

Breed:

Color:

Gender:

Male Female Unknown

Is your pet spayed or neutered?

Yes No Unknown

What is the reason for your pet's visit today?

Is your pet currently taking any medications?

Yes No Unknown

If you answered yes, please list the medications that your pet is currently taking:

Has your pet experienced any of these symptoms within the last 5-7 days? Select ALL that apply:

Coughing Sneezing Vomiting Diarrhea Weakness Lethargy Pain or discomfort Other None

If you selected any of the symptoms above, please describe in more detail:

We respect your privacy and will not sell, trade or rent any of your personal, identifiable information. The options below are for communications from our clinic to you, and will not be used for any other reason.

Thank you for becoming a part of our family! We truly care about you and your pet(s) and look forward to communicating with you throughout the year. Please select which method(s) you would prefer Jefferson Animal Clinic to contact you by: *

Direct Mail (Postal Service) Phone Call Email Text Messaging

Jefferson Animal Clinic uses social media along with our website and veterinary forums and journals to share pictures of newly adopted pets, share pictures of our beloved new patients and share interesting facts and findings for public education when we can.

By allowing Jefferson Animal Clinic to release media such as photographs, video images, and portions of your pet's medical history and records, you agree not to file any claim for revenue or lawsuit for damages against Jefferson Animal Clinic.

You understand that no client names will be used unless specific authorization has been obtained. You also understand that this information may be used in print media, social media, for brochures or on the Jefferson Animal Clinic website and agree to its use in that manner.

(Facebook and Instagram are the two social media platforms currently used by Jefferson Animal Clinic.)

Do you give Jefferson Animal Clinic permission to release media and information about your pet? *

Yes No

Signature: *

Clear