New Client Information Form

Client Information Form
The Human(s)
Owner/Account Holder Name*

First NameLast Name
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone Number*
Please enter a valid phone number.
Email Address*
example@example.com
Spouse/Significant Other (anyone who can make medical and/or financial decisions on your behalf)

First & Last NameRelationship
Would you like to add anyone else as an authorized account holder?

First & Last NameRelationship
Please note that any individuals listed as account holders on this form will be granted full access to the account until we are notified in writing otherwise.
Spouse/Significant Other Phone
Please enter a valid phone number.
How did you hear about us?*
If this was a personal or professional referral, who can we thank?
First & Last Name or Business Name
The Pets
Pet's Name*
Pet's Species*

CatDog
Pet's Date of Birth or Estimated Age*
ie: 1/24/2010 or 11y
Pet's Breed & Color(s)/Marking(s)*
ie: Lab mix, black w/ white feet & chest
Pet's Sex*

MaleFemale
Spayed/Neutered?*

YesNo
Any known allergies to medications or vaccines? If so, please explain:*
Any serious or major medical concerns of which we should be aware? If yes, please explain:*
Second Pet's Name
Pet's Species

CatDog
Pet's Date of Birth or Estimated Age
ie: 1/24/2010 or 11y
Pet's Breed & Color(s)/Marking(s)
ie: Lab mix, black w/ white feet & chest
Pet's Sex

MaleFemale
Spayed/Neutered?

YesNo
Any known allergies to medications or vaccines? If so, please explain:
Any serious or major medical concerns of which we should be aware? If yes, please explain:
Love pets as much as we do and have more than two? Ask one of our Client Services Representatives for an extra page!
Prior to your first appointment date, please remit your pet's medical history and/or breeder adoption records to info@belmontanimalhospital.com (include yourname and your pet's name in the subject) and provide the name, city and state of the veterinary practice that has medical records for your pet(s). If your pet has visited more than one, please separate them by a | in the fields below.

Name of Veterinary PracticeCity & State of Veterinary Practice
If the name provided above does not match the name on the account with the other veterinary practice(s) please indicate the other account-holder-name so we can ensure your pet's records are properly synced with your pet's chart.
First & Last Name
I authorize Belmont Animal Hospital, its authorized representatives and employees, to take pictures, photographs, film or video recordings, audio recordings, digital images and the like (collectively, "Pictures") of my pet(s) and my property in connection with the aforementioned pet(s). I authorize Belmont Animal Hospital, its assignees and transferees to copyright, use and publish the same in print and/or electronically. I agree that Belmont Animal Hospital may freely use such pictures of my pets(s) for any lawful purpose, including but not limited to publicity, illustration, advertising, web content and social media posting.*

YesNo
Appointment Attendance Policy
Arriving 15 or more minutes late will be treated as a “work-in” which will be seen between our on-time appointments when possible. Depending on our patient load at that time, it may result in extended wait times or our offering to reschedule that appointment for a future date.

Appointments arriving late by 30 minutes or more will be considered as failure to appear and will result in future appointments requiring a deposit*.

Any appointments needing to be cancelled or rescheduled should be done at least 24 hours in advance; failure to do so will result in future appointments requiring a deposit*.

Anyone who does not show up for a scheduled appointment will result in future appointments requiring a deposit*.

Appointment reservation deposits will be applied to the appointment but will be forfeit if that appointment is missed or not rescheduled/canceled at least 24 hours in advance.
By signing below I state that all of the information is true and accurate to the best of my knowledge, and that I understand and will respect the Appointment Attendance Policy. I also state that I am the owner and responsible party for the animal(s) listed above and that I, and other individuals listed above, have the decision making authority regarding the care and treatment for those pets.
Signature of Owner / Account Holder

Clear
Today's Date

MonthDayYear
Date
Should be Empty:

Client Information Form

The Human(s)

The Pets

Love pets as much as we do and have more than two? Ask one of our Client Services Representatives for an extra page!

Appointment Attendance Policy