VHNW New Client/Patient Form

Date

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

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?

Who referred you?

Pet Information

Pet's Name

Age

(wks/mos/yrs)

Birthdate

Other

Sex

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

Reason for obtaining pet (check all that apply):

Describe your pet's diet:

If Table food seleced, please select how often it is fed:

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:

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).

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

PHOTO RELEASE