New Client Intake Form

New Client Form
Primary Contact*

First NameLast Name
Primary Phone Number*
Please enter a valid phone number.
Do you have an appointment already scheduled? Please let us know if you are wanting to schedule an appointment if we have not done so already. *
Is this a cell phone or landline number?
Physical Address*

Street Address - Please do not list PO Box

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Email*
example@example.com
Who was your previous family veterinarian? *
*We will call for your pets records*
Secondary Contact Information
Would you like to add a secondary contact to your account?*
Note: The secondary contact will be financially responsible for all charges incurred in the event FurWell Animal Hospital cannot reach the primary contact.
Secondary Contact Full Name

First NameLast Name
Secondary Contact Primary Phone Number
Please enter a valid phone number.
Secondary Contact Email
example@example.com
Referral Information
Were you referred to FurWell Veterinary Hospital by a current client?*
Family/Friend who referred you?

First NameLast Name
Phone number of referring family/friend
Please enter a valid phone number.
If making a future appointment for one of your pets please let us know who the appointment is for and what we will be seeing them for.
FurWell Veterinary Hospital values clients who refer us to their friends and family, as well as those who have been referred to our practice. This allows us to continue to grow in our community and maintain the highest reputation for being one of the best in the business. We want to thank you for your continued support by giving you $25 off your next bill. In addition, we will also be giving $25 credit to the pet parent who sent you our way!

By signing below, I hereby authorize that all of the above information is correct. I also authorize the veterinarian to examine, prescribe for, and/or treat my pets. I assume full responsibility for all charges incurred for the care of my pets I have on my account. I also understand that these charges will be paid at the time of release and that a deposit may be required depending on the services needed. I understand and agree to the below hospital policies.
Client Signature*

Clear

Pet(s) Information
Pet #1 Name*
Breed*
Color*
Sex*
Are they spayed or neutered?*

YesNo
Estimated Birth Date*

MonthDayYear
Current Medication(s)*
Please list name and dose of medication, including current heartworm & flea/tick prevention.
We'd love to see a photo of your pet! (Any photo you upload of your pet is for in-clinic use only and will not be shared)
Any Additional Pet's You Would Like to Add to Your Account? *

Pet #2 Information
Pet #2 Name
Breed
Color
Sex
Estimate Birth Date

MonthDayYear
Current Medication(s)
Please list name and dose of medication, including current heartworm & flea/tick prevention.

Pet #3 Information
Pet #3 Name
Breed
Color
Sex
Estimated Birth Date

MonthDayYear
Current Medication(s)
Please list name and dose of medication, including current heartworm & flea/tick prevention.

Do you give FurWell Veterinary Hospital permission to use photos of your pet(s) taken in clinic on their social media pages?*

YESNO
Client Signature*

Clear
Should be Empty:

New Client Form

Secondary Contact Information

Referral Information

Pet(s) Information