New Client/Patient Information

New Client/Patient Information

if you are a new client, welcome! if you're an existing client with a new pet, congratulations! Please provide us with or update your information and tell us about your pet.
Name*

First NameLast Name
Preferred Salutation*
Name of spouse, partner, or significant other*
Preferred Salutation*
Please share your occupations and employers.*
Number of children in your home, names, and ages. This information helps us assess the overall health risks for your household.*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone numbers: please provide home, cellular, work and identify type of number. Please list primary contact number first. *
Email address*
Would you like to receive reminders for your pet(s) via email?*
How were you referred to us?
If you were referred by a friend, please let us know who that was!
Our payment policy is for payment to be completed when services are provided. We accept cash, check, VISA, Mastercard, Discover, AMEX, and Care Credit. Do you understand and accept these terms?*
Do we have your permission to post photos of your pets on our social media accounts?*
Information about your pet
Now we need to know all about your pet. What is your pets' name? *
Your pets' date of birth:*

MonthDayYear
Date
FemaleMaleFemale SpayedMale neutered
Species*
Breed*
What color is your pet?*
Name(s) of other veterinary hospitals who have provided care. If none, please type "none".*
Dates of most recent vaccines*
Date of last dental cleaning*
Major medical history, including any allergic reactions to vaccines or medications. If none, tell us "N/A"*
Is your pet insured? If so, please tell us by which company. *
Has your pet ever needed tranquilizers or any protective device (ex: muzzle, kitty restraint bag) to have a successful veterinary visit? If so, there's no shame in that - we just want to make the visit as low stress as possible and protect both your pet and our people. If so, please describe that below. If no, then just say No.
Thank you!

We appreciate you taking the time to give us this information! There may be additional forms we'll ask you to complete as well.
By submitting this form, you agree to the Southwest Veterinary Hospital, PC Code of Conduct:

Our entire team is dedicated to giving our best to you and your beloved pets, which includes treating you with courtesy and respect.

In return, I expect every client to do the same for our team.

From this point forward, all forms of disruptive behavior are prohibited in our office. Incidents of disruption, verbal aggression in person, via email, or on the phone, and/or threats of violence will result in your exclusion from our practice.

Examples of prohibited behaviors include but are not limited to:

Threats, Physical aggression, Verbal harassments, including abusive language, cursing, shouting, and/or sexual comments, Demeaning behavior and comments, Failure to follow facility policies and procedures

Thank you for being kind and helping everyone be safe.

EFFECTIVE NOVEMBER 1, 2022: A $50 non-refundable deposit is required for all new client appointments. This deposit will be collected when your appointment is scheduled.
Has your pet ever needed tranquilizers or a protective device like a muzzle or kitty bag to have a successful veterinary visit? There's no shame in that! We want your pet to have a good visit, but we also need to keep everyone safe, so please describe what help your pet has needed! If none, simply type N/A*
Should be Empty:

New Client/Patient Information

Information about your pet

Thank you!