CLIENT & PATIENT INFORMATION SHEET

New Client & Patient Information Sheet

Park Veterinary Hospital
(Primary)Owner #1*

First NameLast Name
Preferred Pronouns: Owner 1
Contact Info: Cell phone*
Thank you for giving PARK VETERINARY HOSPITAL the opportunity to care for your pet. So that we may best serve you, please complete the following:
May we send you text reminders/updates?*

YesNo
Email
example@example.com
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Owner #2

First NameLast Name
Preferred Pronouns: Owner 2
Contact Info: Cell phone
E mail Address
example@example.com
May we send you text reminders/updates?

YesNo
Children (if any) Age (s)
Owner #1 Place of Employment

EmployerJob Title
Work Phone Number
Please enter a valid phone number.
If necessary, may we call you at work?

YesNo
Owner #2 Place of Employment

EmployerJob Title
Work Phone Number
Please enter a valid phone number.
If necessary, may we call you at work?

YesNo
How did you become aware of our hospital? Please check all that apply.*

Hospital SignWebsiteSearch EngineOther
Personal Recommendation - Whom may we thank? First Name Last Name
Please Read and Sign(optional):

I grant to Park Veterinary Hospital. its representatives, and employees the right to take photographs of my pet. and to copyright use and publish the same in print and/or electronically. I agree that Park Veterinary Hospital may use such photographs of my pet with or without their name and for any lawful purpose. including. for example, such purposes as publicity. illustration, advertising, and Web content.
Signature

Clear
Today's Date

MonthDayYear
Date
Pet Information
Please fill in the appropriate information for each pet you own.
Pet #1
Pets Name:Pets name*
           Sex:   *
Spayed/Neutered:     *
Date of Birth: Date of Birth*
Age When Obtained:     Age When Obtained*
Obtained from & When:   *
Species:*
Breed:*
Color:Pet's color*
Lifestyle:*
Microchipped:   Yes/No*
Heartworm Prevention:  I.e. Simparica Trio*
Flea/Tick Control: I.e. Simparica Trio*
Known Allergies:  List Allergies Here*
Special Diet: Special Diet*

Do you have other pet(s) at home?Yes   No
Pet #2
Pets Name:Pets name
           Sex:
Spayed/Neutered:
Date of Birth: Date of Birth
Age When Obtained:     Age When Obtained
Obtained from & When:
Species:
Breed:
Color:Pet's color
Lifestyle:
Microchipped:   Yes/No
Heartworm Prevention:  I.e. Simparica Trio
Flea/Tick Control: I.e. Simparica Trio
Known Allergies:  List Allergies Here
Special Diet: Special Diet

Do you have other pet(s) at home?Yes   No
Pet #3

Pets Name:Pets name
             Sex:
Spayed/Neutered:
Date of Birth: Date of Birth
Age When Obtained:     Age When Obtained
Obtained from & When:
  Species:
Breed:
Color:Pet's color
Lifestyle:
Microchipped:
Heartworm Prevention:  I.e. Simparica Trio
Flea/Tick Control: I.e. Simparica Trio
Known Allergies:  List Allergies Here
Special Diet: Special Diet
Previous veterinarian(s) where records could be obtained
Is there anything we need to know about any of your pets to safely examine and treat them?
Please list. per pet. any prior illnesses or surgeries, allergies, and current medications or supplements
Do you or any family member have a peanut allergy (we often use peanut butter for treats)?*

YesNo
I, THE UNDERSIGNED, 1) ASSUME RESPONSIBILITY FOR ALL CHARGES INCURRED IN THE CARE OF MY PET(S), AGREEING THAT THESE CHARGES WILL BE PAID AT THE TIME OF RELEASE AND THAT A DEPOSIT MAY BE REQUIRED

FOR TREATMENT; AND 2) GIVE PERMISSION FOR RELEASE OF MY PET's MEDICAL RECORDS FROM THE ABOVE-LISTED VETERINARIAN.

I authorize the following additional individuals to present the above-named, and any future pets, for treatment.
Owner #1 Name*
Relationship
Owner #1 Signature*

Clear
Today's Date*

MonthDayYear
Date
Owner #2 Name
Relationship
Owner #2 Signature

Clear
Today's Date

MonthDayYear
Date
I grant to Park Veterinary Hospital, its representatives, and employees the right to take photographs of my pet, and to copyright use and publish the same in print and/or electronically. I agree that Park Veterinary Hospital may use such photographs of my pet with or without thier name and for any lawful purpose, including, for example, such purposes as publicity, illistration, advertising, and web content.
Signature

Clear
Should be Empty:

New Client & Patient Information Sheet

Pet #3