New Client Form

New Client Form

Please complete both this and the patient history form before your appointment - they will take approximately 20 minutes. If you prefer to fill out a pdf version, please contact us and we can send you a copy. If you wish to fill out these forms at our office, please arrive 30 minutes before your appointment or you may be asked to reschedule.
Owner Information:
Owner #1 - Please state your name and preferred pronouns
Owner #2 - Please state your name and preferred pronouns
Address
City
Zip
Phone
Email Address
example@example.com
Secondary Owner Phone Number
Please enter a valid phone number.
Primary Veterinarian Name
Please include first and last name if known
Primary Veterinary Hospital
Primary Veterinary Hospital Phone Number
Please list the names and contact numbers of any other veterinary hospitals your pet has visited.
How did you hear about us?
Preferred method of contact

Phone callEmail
Would you like to be added to our cancellation list?

YesNo
Pet Information:
Name of Pet
Species (Dog, Cat, Rabbit, etc.)
Breed
Sex
Please also note if they are spayed or neutered
Age/Date of Birth
Color
Drug Allergies/Medication Reactions
Please fill out the following information for any additional pets in your household:
Additional Pet #1:
Name
Species
Breed
Age
Additional Pet #2:
Name
Species
Breed
Age
Additional Pet #3:
Name
Species
Breed
Age
We often take photographs of patients in order to document their progress during treatment. These photographs can be very helpful teaching materials in lectures to local veterinary hospitals, and also make interesting case discussions on social media. Will you grant us permission to use your pet's photographs in lectures and on social media? Your pet's first name will be used, but your last name will not be included. If you do not consent, your pet's photographs will be used solely for their medical records and will not be shared with others.
Signature of Owner

Clear
Date

MonthDayYear
Date
Please Read Closely and Initial Each of the Following Statements:

Appointment Timing and Requirements

Staying on time for our appointments with you is very important to us at Pet Dermatology Partners. We have a 10 minute late policy for all clients. If you arrive more than 10 minutes late to your appointment, you may be asked to reschedule this appointment.
Initial
Your new client and patient forms must be completed when you arrive for your appointment. Completing these forms in the office often takes longer than our 10 minute late policy allows, so if your new client and patient forms are not completed when you arrive you may be asked to reschedule your appointment. If you need to fill out these forms in our office before your appointment, you must call to let us know and arrive 30 minutes early to do so.
Initial
If you need to reschedule or cancel an appointment, you must contact us more than 24 hours before your scheduled appointment time. If you fail to do this, we may require you to prepay for your pet's next appointment.
Initial
Examination and Treatment Explanations

Pet Dermatology Partners specializes in the treatment of skin diseases. As such, your pet's examination and treatment will focus on his or her dermatological problems. If your pet has any other medical or surgical needs, this should be addressed by your pet's primary veterinarian.
Initial
I am the owner/agent for (pet's name) blanks and I grant permission for Pet Dermatology Partners to examine/treat my pet.
Initial
If your pet has been aggressive towards other humans or animals, please tell our office before your appointment and muzzle your pet before entry into our building. Your pet must remain muzzled during their entire appointment unless we direct you otherwise. Failing to comply with this safety requirement may result in our inability to examine your pet and retain you as a client.
Initial
Examination and Treatment Charges

All fees incurred are due, in full, at the time of service. We accept cash, Visa, and Mastercard. We do not take checks. We do not accept American Express or offer payment plans.
Initial
I accept financial responsibility for all charges incurred in the treatment of my pet.
Initial
If your pet receives allergy serum as part of their treatment, this serum must be paid for before it is prepared by Pet Dermatology Partners.
Initial
By signing below, you are hereby acknowledging that you have read and understood all the above statements. A copy of this form can be given to you upon request.
Client name
Client Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

New Client Form

Owner Information:

Pet Information:

Please fill out the following information for any additional pets in your household:

Additional Pet #1:

Additional Pet #2:

Additional Pet #3:

Please Read Closely and Initial Each of the Following Statements: