NEW PATIENT FORM

New/Additional Patient 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. IF YOU ARE A NEW CLIENT, PLEASE ALSO FILL OUT THE NEW CLIENT FORM ON OUR WEBSITE. THANK YOU!
Existing Client Information
Client Name

First NameMiddle NameLast Name
Phone Number*

Area CodePhone Number
Pet Information
NAME OF PET*
TYPE OF PET*

DOGCATOther
SEX*

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*
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 RELEASE AND THAT A DEPOSIT MAY BE REQUIRED FOR SURGICAL TREATMENT OR HOSPITALIZATION.
SIGNATURE*

Clear
DATE OF SIGNATURE*

MonthDayYear
Date
Should be Empty:

New/Additional Patient Form