Green Cove - New Clients Form

1
Date
Date
Month
Day
Year
2
Owner Name* This field is required.
Mrs.
Mrs.
Mr.
Ms.
Dr.
Prefix
First Name
Middle Name
Last Name
3
Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
4
Owner Contact Information*Please note: if you would like text reminders your primary number must be a cell phone number.
Primary Number
Please Select
Please Select
Cell Phone
Landline
Is Primary Number Cell Phone/Landline?
Secondary Number
Please Select
Please Select
Cell Phone
Landline
Is Secondary Number Cell Phone/Landline?
Work Number
Please Select
Please Select
Cell Phone
Landline
Is Work Number Cell Phone/Landline?
Email
5
Spouse/Co-Owner Name
Mrs.
Mrs.
Mr.
Ms.
Dr.
Prefix
First Name
Middle Name
Last Name
6
Spouse/Co-Owner Contact Information*Please note: if you would like text reminders your primary number must be a cell phone number.
Primary Number
Please Select
Please Select
Cell Phone
Landline
Is Primary Number Cell Phone/Landline?
Secondary Number
Please Select
Please Select
Cell Phone
Landline
Is Secondary Number Cell Phone/Landline?
Work Number
Please Select
Please Select
Cell Phone
Landline
Is Work Number Cell Phone/Landline?
Email
7
Would you like to receive e-reminders and coupons from Green Cove Pet Hospital?* This field is required.
Yes
No
8
How did you hear about us?
Yellow Pages
Hospital Sign
Radio
Google
Facebook
Personal Recommendation
Other
9
Whom can we can thank?
10
Please list Other
11
Method of Payment

Payment is required at the time of service. For your convenience, we accept Mastercard, NOVUS/Discover, Visa, American Express, Care Credit, cash, or check. We must have a Photocopy of your current driver’s license to accept any form of payment.
12
How much information do you want to be given about your pet’s health?
I want a full explanation - anything and everything.
I want a brief explanation - just the important stuff.
I just want to know if there is anything I need to do - keep it simple.
13
Have you or your pet traveled outside of Alabama state in the last 14 days?
YESNO
14
Have you, someone in your home or your pet experienced respiratory symptoms (coughing, sneezing, wheezing, or fever) in the last 14 days?
YESNO
15
Have you or someone in your home been asked by a health care professional and/or the department of health/CDC to quarantine in the last 14 days?
YESNO
16
Appointment Procedures* This field is required.
I understand that payment is due in full at the time services are rendered. This includes services authorized by my proxy; by another responsible party listed on my account; and/or by phone.
17
Cancellation Policy* This field is required.
Green Cove Pet Hospital requires 24 hours’ notice to reschedule or cancel an existing appointment. If an appointment is missed or rescheduled with improper notice, you will be required to pre-pay for exams or schedule as a day admission appointment going forward. The pre-paid exam fee is nonrefundable but will be applied to your invoice at your appointment. If you miss, reschedule, or cancel the appointment without proper notice, you forfeit the exam fee deposit.
18
In appreciation of you filling out our New Client Form ahead of time, we want to offer you

$30 off your first wellness exam.
19
#1 Pet Information
Pet Name
Please Select
Please Select
Male
Male Neutered
Female
Female spayed
Sex
Species (Cat, Dog, etc)
Breed
Color
Weight in pounds
When is your pet's birthday?
20
What is Your Pet's Age?
Years
Months
21
Do you have pet Insurance?
Yes
No
22
Does your pet have Allergies?
Yes
No
23
Has your pet ever had a reaction to vaccines or medications?
Yes
No
24
If yes, please describe
25
List any major surgeries your pet has had
26
List any behavior problems we need to be aware of
27
Does Your Pet Have Known Health Concerns and/or Chronic Disease or Conditions?
YESNO
28
If yes, Tell us more
29
List heartworm prevention used/last given
30
List Flea tick prevention used/last given
31
Do you have any other pets to add?* This field is required.
Yes
No
32
#2 Pet Information
Pet Name
Please Select
Please Select
Male
Male Neutered
Female
Female spayed
Sex
Species (Cat, Dog, etc)
Breed
Color
Weight in pounds
When is your pet's birthday?
33
What is Your Pet's Age?
Years
Months
34
Do you have pet Insurance?
Yes
No
35
Does your pet have Allergies?
Yes
No
36
Has your pet ever had a reaction to vaccines or medications?
Yes
No
37
If yes, please describe
38
List any major surgeries your pet has had
39
List any behavior problems we need to be aware of
40
Does Your Pet Have Known Health Concerns and/or Chronic Disease or Conditions?
YESNO
41
If yes, Tell us more
42
List heartworm prevention used/last given
43
List Flea tick prevention used/last given
44
Do you have any other pets to add?* This field is required.
Yes
No
45
#3 Pet Information
Pet Name
Please Select
Please Select
Male
Male Neutered
Female
Female spayed
Sex
Species (Cat, Dog, etc)
Breed
Color
Weight in pounds
When is your pet's birthday?
46
What is Your Pet's Age?
Years
Months
47
Do you have pet Insurance?
Yes
No
48
Does your pet have Allergies?
Yes
No
49
Has your pet ever had a reaction to vaccines or medications?
Yes
No
50
If yes, please describe
51
List any major surgeries your pet has had
52
List any behavior problems we need to be aware of
53
Does Your Pet Have Known Health Concerns and/or Chronic Disease or Conditions?
YESNO
54
If yes, Tell us more
55
List heartworm prevention used/last given
56
List Flea tick prevention used/last given
57
Record Transfer

To best serve you and your pet we will need copies of any recent medical history, Please, complete the following to permit us to collect your pet's medical history.
58
Pet's Name
Species
59
I authorize the release of a copy of the medical records for the above listed animal(s)
From previous veterinary clinic(s)
Phone
Fax
Is this a permanent transfer?
60
In the future, If patient records are requested from Green Cove Pet Hospital for any of your pets for another professional facility ( i.e veterinary clinic, grooming, boarding. day care, etc.) are we permitted to release the requested medical history?
Yes, Release the requested medical history
61
Photography/Video Release Policy
Yes, you can take photographs of my pet
No, you can not take photographs of my pet
62
Date
Date
Year
Month
Day
63
Pet Owner Signature* This field is required.
Clear
Should be Empty:

Method of Payment

What is Your Pet's Age?

What is Your Pet's Age?

What is Your Pet's Age?