New Client/Patient Registration Form

New Client/Pet Info

Boulder Creek Veterinary Clinic
Pet name
Species

CanineFelineOther
Gender

MaleNeutered MaleFemaleSpayed Female
Breed
Color
Pets Birthdate

MonthDayYear
Date
Medications (list all)
Diet (List brand/s fed)
Microchip #
Is your pet on any Flea Control or Heartworm Prevention? If yes, what type? (name or brand)
Pet #2
Pet #2 name
Species

CanineFelineOther
Gender

MaleNeutered MaleFemaleSpayed Female
Breed
Color
Pets Birthdate

MonthDayYear
Date
Medications (List all)
Diet (List brand/s)
Microchip #
Is your pet on any Flea Control or Heartworm Prevention? If yes, what type? (name or brand)
Owner Information
Full Name

First NameLast Name
Spouse/Co-Owner

First NameLast Name
Phone Number

Area CodePhone Number
Spouse/Co-Owner Phone Number

Area CodePhone Number
E-mail
example@example.com
Spouse/Co-Owner E-mail
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Primary Client Birthdate
(Used for Controlled Substance Prescriptions)
Primary Contact Drivers License #
(Used for Controlled Substance Prescriptions)
Primary Contact Drivers License Expiration
(Used for Controlled Substance Prescriptions)
Vet Records & Info

We require previous records for all new patients before your appointment. Our doctors & staff review records prior to the patient coming in. If you do not have records to upload, please give us the name and number of your previous veterinarian and any other names associated with your pets account, so that we may locate the records. If you do not have previous veterinary information, please put N/A in the box. We will accept screen shots uploaded of records as long as they are legible and clear. If we do not receive records prior to your appointment and we have to get them during your exam, it may incur additional charges during your visit.
Previous Veterinarian Name*
Previous Veterinarian Phone Number*

Area CodePhone Number
UPLOAD ANY PREVIOUS MEDICAL RECORDS HERE

Browse Files

Cancelof
Emergency Contact
Full Name

First NameLast Name
Phone Number

Area CodePhone Number
Should be Empty:

New Client/Pet Info

Pet #2

Owner Information

Vet Records & Info

Emergency Contact