NEW CLIENT FORM

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 NameMiddle NameLast Name
Spouse/Partner's Name

First NameMiddle NameLast Name
DL#/STATE (required for checks and care credit)
Primary Phone Number*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email Address (write none if you don't use email)*
example@example.com
Spouse/Partner Phone Number

Area CodePhone Number
Alternate Phone Number

Area CodePhone Number
How did you learn about our hospital?
PET HEALTH HISTORY
NAME OF PET*
DOGCATOther
MALE INTACTMALE NEUTEREDFEMALE INTACTFEMALE 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*

Clear
DATE OF SIGNATURE*

MonthDayYear
Date
AMEXCARE CREDITCASHDISCOVERMASTERCARDVISASCRATCHPAYCHECKAPPLE PAY
Should be Empty:

New Client Form