Pet Wellness Group New Client Form

New Client Registration
Thank you for giving us the opportunity to be your pet's provider of veterinary services. We are dedicated to maintaining the health of your pet and look forward to many future years together. Please take the time to complete this form completely which will help expedite the registration process and give us valuable insight in providing optimal care for your pet(s).

*=required
Contact Information
Owner Name*

First NameLast Name
Owner Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
Cell Phone
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
E-mail*
example@example.com
Spouse Or Co-Owner

First NameLast Name
Additional Phone Number
Please enter a valid phone number.
Preferred Method Of Contact

EmailTextPhoneAllOther
Are you Active Military, Veteran or First Responder? If so, present your ID card for special benefits.

YesNo
How did you hear about us?*

Walked/Drove ByTV/Radio/NewspaperHospital EmployeeGoogle/Bing/YahooCard/Flyer/MailerFacebook/InstagramBoarding/GroomingYelpShelterOther - (Existing Client, Hospital/Veterinarian, etc.)
Indicate Type And Quantity Of Other Pets In Your Household

Dogs blanks
Cats blanks
Ferrets blanks
Rabbits blanks
Rodents blanks
Birds blanks
Reptiles blanks
Other blanks
Pet Information
Pet's Name*
Date of Birth or Age (if known)*

MonthDayYear
Date
Microchip #
Species*

DogCatRabbitFerretBirdReptileOr if other species
Breed (if known)*
Color*
Gender
Medical Conditions (Allergies, Drug Reactions, Heart Conditions, Etc.)
Do you have another pet to add?

YesNo
Pet #2 Information
Pet's Name*
Date of Birth or Age (if known)*

MonthDayYear
Date
Microchip #
Species*

DogCatRabbitFerretBirdReptileOr if other species
Breed (if known)*
Color*
Gender
Medical Conditions (Allergies, Drug Reactions, Heart Conditions, Etc.)
Photo Consent: We love social media! Do we have your permission to share your pet(s)' image and story on social media, our website, and other forms of related media? Your name and personal information will never be shared. Simply check below to authorize this.

Yes, I authorize Pet Wellness Group to share my pet's photo and story.No, I do not authorize this.
I authorize for Pet Wellness Group to obtain my full veterinary medical records for all pets from the following previous veterinarians:
Payment is due upon completion of services. Accounts overdue greater than 30 days will be charged a service charge amount of 1.5% on the unpaid balance, but not less than $1.00. *

Clear
Today's Date

MonthDayYear
Date
Should be Empty:

New Client Registration

Contact Information

Pet Information

Pet #2 Information