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
Client Information
Owner Name
*
First Name
Last Name
Owner Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
County
*
Phone Number
*
E-mail
*
example@example.com
Spouse/Secondary Owner
First Name
Last Name
Spouse/Secondary Owner Phone Number
Please enter a valid phone number.
How did you hear about us?
*
Walked/Drove By
TV/Radio/Newspaper
Hospital Employee
Google/Bing/Yahoo
Card/Flyer/Mailer
Facebook/Instagram
Boarding/Grooming
Yelp
Shelter
Other - (Existing Client, Hospital/Veterinarian, etc.)
Please use this area to give us any other relevant information about yourself, family, and other pet's in the household:
Pet #1 Information
Pet's Name
*
Breed (if known)
*
Date of Birth or Age (if known)
*
-
Month
-
Day
Year
Date
Color
*
Spayed/Neutered
Yes
No
Is this a dog or cat?
Dog
Cat
Our Pet Is A
Member Of The Family
Service Animal
Foster Animal
Show Animal
Any Previous Illnesses Or Surgeries?
Any Allergies To Vaccines Or Medications?
Please List The Names Of Any other family members/person(s) that we may release medical information to.
Is Your Pet On Any Special Diet Or Medication?
Rabies Vaccine - Date Performed
DAPP Vaccine - Date Performed
Bordetella (Kennel Cough) - Date Performed
Leptospirosis Vaccine - Date Performed
Lyme Disease Vaccine - Date Performed
Influenza Vaccine - Date Performed
Last Heartworm Test - Date Performed
Type of Prevention Used
Our Pet Is A
Member Of The Family
Service Animal
Foster Animal
Show Animal
Any Previous Illnesses Or Surgeries?
Any Allergies To Vaccines Or Medications?
Please List The Names Of Any other family members/person(s) that we may release medical information to.
Is Your Pet On Any Special Diet Or Medication?
Rabies Vaccine - Date Performed
FVRCP Vaccine - Date Performed
Leukemia Vaccine - Date Performed
Leukemia / FIP Test - Date Performed
Do you have another pet to add?
Yes
No
Pet #2 Information
Pet's Name
*
Breed (if known)
*
Date of Birth or Age (if known)
*
-
Month
-
Day
Year
Date
Color
*
Spayed/Neutered
Yes
No
Is this a dog or cat?
Dog
Cat
Our Pet Is A
Member Of The Family
Service Animal
Foster Animal
Show Animal
Any Previous Illnesses Or Surgeries?
Any Allergies To Vaccines Or Medications?
Please List The Names Of Any other family members/person(s) that we may release medical information to.
Is Your Pet On Any Special Diet Or Medication?
Rabies Vaccine - Date Performed
DAPP Vaccine - Date Performed
Bordetella (Kennel Cough) - Date Performed
Leptospirosis Vaccine - Date Performed
Lyme Disease Vaccine - Date Performed
Influenza Vaccine - Date Performed
Last Heartworm Test - Date Performed
Type of Prevention Used
Our Pet Is A
Member Of The Family
Service Animal
Foster Animal
Show Animal
Any Previous Illnesses Or Surgeries?
Any Allergies To Vaccines Or Medications?
Please List The Names Of Any other family members/person(s) that we may release medical information to.
Is Your Pet On Any Special Diet Or Medication?
Rabies Vaccine - Date Performed
FVRCP Vaccine - Date Performed
Leukemia Vaccine - Date Performed
Leukemia / FIP Test - Date Performed
Previous Vet Name, Hospital Name, and Location
*
If you have your pet(s) records, please upload them here:
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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 Archer Veterinary Clinic to share my pet's photo and story.
No, I do not authorize this.
Treatment Consent: I hereby authorize the veterinarian to examine, prescribe for or treat the above described pet(s). I assume responsibility for all charges incurred in the care of this animal. I understand that payment is always due IN FULL at time of service and that a deposit may be required for hospitalization and surgical procedures. I recognize that financial concerns should be discussed PRIOR to examination and treatment. The Archer Veterinary Clinic staff is happy to provide estimates. I understand that Archer Veterinary Clinic does not bill.
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