New Client Form

College Garden Animal Hospital (575)624-2424 502 E College Roswell, NM 88201 www.collegegardenanimalhospital.com

Date*

Date

Client Name*

Client Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Primary Phone Number*

Primary Phone Type:*

Email*

example@example.com

Would you like to list a Co Owner on your account?*

Co Owner's Name

Co-Owner's Phone number

How many pets would you like to register?*

Pet 1 Name*

Pet 1 Age/Date of Birth*

Date

Pet 1 Species*

Pet 1 Breed*

Pet 1 Sex*

Pet 1 Color/Markings*

Pet 1: Is your pet microchipped?*

Pet 1: Does your pet have any known allergies or drug reactions?*

Pet 1: Is your pet currently being treated for any medical conditions?*

Pet 1: Has this pet had any previous medical problems or issues?*

Pet 1: We love sharing photos of our wonderful clients! Do we have your consent to share your pet's image on our social media channels and website? We will never use your full name or personal information.*

Pet 2 Name

Pet 2 Age/Date of Birth

Date

Pet 2 Species

Pet 2 Breed

Pet 2 Sex

Pet 2 Color/Markings

Pet 2: Is your pet microchipped?

Pet 2: Does your pet have any known allergies or drug reactions?

Pet 2: Is your pet currently being treated for any medical conditions?

Pet 2: Has this pet had any previous medical problems or issues?

Pet 2: We love sharing photos of our wonderful clients! Do we have your consent to share your pet's image on our social media channels and website? We will never use your full name or personal information.

Pet 3 Name

Pet 3 Age/Date of Birth

Date

Pet 3 Species

Pet 3 Breed

Pet 3 Sex

Pet 3 Color/Markings

Pet 3: Is your pet microchipped?

Pet 3: Does your pet have any known allergies or drug reactions?

Pet 3: Is your pet currently being treated for any medical conditions?

Pet 3: Has this pet had any previous medical problems or issues?

Pet 3: We love sharing photos of our wonderful clients! Do we have your consent to share your pet's image on our social media channels and website? We will never use your full name or personal information.

Pet 4 Name

Pet 4 Age/Date of Birth

Date

Pet 4 Species

Pet 4 Breed

Pet 4 Sex

Pet 4 Color/Markings

Pet 4: Is your pet microchipped?

Pet 4: Does your pet have any known allergies or drug reactions?

Pet 4: Is your pet currently being treated for any medical conditions?

Pet 4: Has this pet had any previous medical problems or issues?

Pet 4: We love sharing photos of our wonderful clients! Do we have your consent to share your pet's image on our social media channels andwebsite? We will never use your full name or personal information.

Does your pet currently have a primary veterinarian?*

Doctor/Practice Name

Practice Phone/Email (to request records)

Does your pet have insurance?*

Insurance Name

How did you hear about our practice?*

I, the undersigned owner or authorized agent of the above admitted patient(s) agree to assume responsibility for all charges incurred, and agree to pay all such charges at the time of service/release.

ALL PROFESSIONAL FEES ARE DUE AT THE TIME SERVICES ARE RENDERED.

Signature*

Date*

Date