New Client Form
WE KNOW YOUR PET’S HEATH IS IMPORTANT AND WE THANK YOU FOR TRUSTING US TO CARE FOR THEM. TO HELP US PROVIDE THE BEST CARE POSSIBLE, PLEASE TAKE A FEW MOMENTS TO FILL OUT THIS FORM COMPLETELY. THANK YOU!
Name
*
First Name
Middle Name
Last Name
Spouse/Partner's Name
First Name
Middle Name
Last Name
DL#/STATE (required for checks and care credit)
Primary Phone Number
*
-
Area Code
Phone Number
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email Address (write none if you don't use email)
*
example@example.com
Spouse/Partner Phone Number
-
Area Code
Phone Number
Alternate Phone Number
-
Area Code
Phone Number
How did you learn about our hospital?
PET HEALTH HISTORY
NAME OF PET
*
TYPE OF PET
*
DOG
CAT
Other
SEX
*
MALE INTACT
MALE NEUTERED
FEMALE INTACT
FEMALE SPAYED
BREED
*
COLOR
*
BIRTHDATE OR AGE
*
VACCINE HISTORY (IF NOT AT THIS CLINIC)
*
CURRENT MEDICATIONS/PREVENTATIVES
*
SIGNIFICANT MEDICAL HISTORY, ALLERGIES, DIETARY
REASON FOR VISIT
*
~~FOR ADDITIONAL PETS, PLEASE FILL OUT A NEW PATIENT FORM ON WEBSITE~~
AUTHORIZATION
*
I HEREBY AUTHORIZE THE VETERINARIAN TO EXAMINE, PRESCRIBE FOR, AND/OR TREAT MY PETS. I ASSUME FULL RESPONSIBILITY FOR ALL CHARGES INCURRED FOR THE CARE OF ALL MY PETS ON MY FILE. I ALSO UNDERSTAND THAT THESE CHARGES WILL BE PAID AT THE TIME OF SERVICE AND THAT A DEPOSIT MAY BE REQUIRED FOR SURGICAL TREATMENT OR HOSPITALIZATION.
SIGNATURE
*
DATE OF SIGNATURE
*
/
Month
/
Day
Year
Date
METHOD OF PAYMENT
AMEX
CARE CREDIT
CASH
DISCOVER
MASTERCARD
VISA
SCRATCHPAY
CHECK
APPLE PAY
Submit
Should be Empty: