VHNW New Client/Patient Form

Date

MonthDayYear
Steve VanWagner, DVM, MS Kim VanWagner, DVM

455 Hwy 150, New Waverly. Texas 77358

Welcome, we are glad you are here!!
New Client Information
Name*

First NameLast Name
Salutation
Mailing Address*

Address

Street Address

CityState

Zip
Physical Address (if different than mailing address)

Street Address

Street Address Line 2

CityState

Zip Code
Home Phone

Area CodePhone Number
Work Phone

Area CodePhone Number
Cell Phone

Area CodePhone Number
Preferred Contact Number

HomeWorkCell
Driver License #
Email Address
example@example.com
Occupation
Employer
Emergency Contact
Emergency Phone

Area CodePhone Number
How did you first hear of Veterinary Hospital of New Waverly?

Phone BookDrove by ClinicPersonal Referral
Who referred you?
Pet Information
Pet's Name
Age
(wks/mos/yrs)
Birthdate
DogCatOther
Sex

MaleFemaleNeuteredSpayed
Coat Type
Breed
Pet spayed/neutered at what age?
(wks/mos/yrs)
Color
What age was pet obtained?
(wks/mos/yrs)
Pet was obtained from

FriendBreederPet ShopStrayHumane Society/ShelterOther
Reason for obtaining pet (check all that apply):

CompanionProtectionBreedingShowOther
Describe your pet's diet:

Dry food onlyCanned food onlyDry/Canned foodTable food
If Table food seleced, please select how often it is fed:

OccasionallyRegularlyAs a sole source of food
Which brand of pet food do you feed? How much? Frequency?
Reason for this visit today
List your pet's current medications (Include dosage)
Please check any symptoms or problems you've noticed with your pet:

Appetite ChangesBehavioral ChangesBreathing ProblemsVomitingEye ProblemsShaking HeadGums BleedingScootingScratchingGaggingThirstLoss of BalanceWeaknessSneezingDepressionIncreased UrinationCoughingLimpingDiarrheaOther
Vaccines: if animals are dropped off, we MUST have proof of current vaccines.
Vaccines (Needed/last received.
I hereby authorize the veterinarian to examine, prescribe for or treat the above described pet. I assume responsibility for all charges incurred in the care of the animal. I also understand that ALL PROFESSIONAL FEES ARE DUE AT THE TIME SERVICES ARE RENDERED. Acceptable Methods of Payment are: CASH, CHECK, CREDIT CARDS (AMEX, DISCOVER, VISA, MASTERCARD), CARE CREDIT.
Signature of client responsible for pet(s).*

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PHOTO RELEASE
I grant full permission to Veterinary Hospital of New Waverly to use any and all images taken of me or of my pets for the sole use of education, advertising and promotion This includes but is not limited to photographic prints and products, cds, dvds. Facebook page, Twitter, You Tube videos, and other social media sites, website blogs, and website display. I certify that I am eighteen (18) years of age or older. I understand that a parent or guardian must complete this form when granting a photo release involving a minor child(ren).
Signature of client

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Should be Empty:

PHOTO RELEASE