New Client Form

New Client Form

Welcome to Wales Animal Clinic. Our staff is dedicated to the optimum in patient care and will do its utmost to make your pet’s stay pleasant and beneficial. Please feel free to ask any questions concerning the treatment of your pet or other policies of the clinic. To help us serve you better, please provide us with the following information.
Date

Month Day Year
Date
Client Information

(All parties listed below must be at least 18 years of age)
Owner’s Name(s): #1
Owner’s Name(s): #2
Cell Phone : #1
Cell Phone : #2
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Email *
example@example.com
Home Phone
Please enter a valid phone number.
Employer
Work Phone
How did you choose our practice?

Clinic Sign Website Humane Society Location Personal Recommendation Other
If Personal Recommendation whom may we thank?
Number of pets in household (please specify by type)
Pet Information

(Need only ONE FORM completed for multiple pet homes)
Pet’s Name *
*

Dog Cat
Sex *

Male Female
Spay/Neuter *

Yes No
Breed *
Birthdate

Month Day Year
Date
Color *
Primary reason for Visit *
List any symptoms or concerns you’ve noticed with your pet *
List your pet’s current medication(s) or special diet *
List any allergies to vaccinations or medications *
Authorization
If your pet is found by someone, may we release your information to that person to help ensure a speedy homecoming? *

Yes No
I hereby authorize the veterinarian to examine, prescribe for, or treat the above described pet. I assume responsibility for all charges incurred in the care of this animal. I also understand that these charges will be paid at the time of release. TREATMENT PLANS are always available by request.
Signature*
Date*
Please list any ADDITIONAL NON-OWNER CONSENT AUTHORIZATION you give PERMISSION TO AUTHORIZE treatment of any/all pet(s) associated with your account. Please understand you are assuming responsibility for any decisions they make regarding your pet(s) as well as all financial obligations associated with those decisions, regardless of the outcome. (All parties listed below must be at least 18 years of age) Client is responsible to notify Wales Animal Clinic of any changes to this form.
NON-OWNER CONSENT
Name(s)
Phone
Please enter a valid phone number.
Should be Empty:

New Client Form

Client Information

Pet Information

Authorization

NON-OWNER CONSENT