Caldwell Mill Animal Clinic New Client Canine Form

Caldwell Mill Animal Clinic
5196 Caldwell Mill Road Birmingham, AL 35244 (205) 991-7986

James Jordan Jr., D.V.M.

William Christenberry, D.V.M.

Andy Sokol, D.V.M.

Nicole Martin, D.V.M.

Jennifer Ham, D.V.M.

Sarah Wentworth, D.V.M.

Peter Velotas, D.V.M.

Sloan Blaylock, D.V.M.
Owner(s)
Home Phone
Address

Address

Street Address Line 2

CityState / Province

Zip Code
Employer
Work Phone
Cell Phone
Emergency Contact
Phone
Email Address
example@example.com
How did you become aware of our clinic? Friend who we may thank?
Clinic Sign?
Social Media (please specify)
All charges due upon release of your pet or when services/products are received. We accept cash, checks, Visa, MasterCard, and Discover. Any balance over 30 days is subject to a 1.5% finance charge and a $3.50 billing fee per month. You agree to paya reasonable attorney's fee and all collection costs charged to any unpaid balance. Discounts or coupons are valid only if charges are paid in full at the time services are rendered Any outstanding balance must be paid in full before additional services or products can be received
Client Signature

Clear
Date

MonthDayYear
Date
Pet's Name
Sex
Date of Birth or approximate

MonthDayYear
Date
Breed
Color
Special Markings
Has your dog been spayed or neutered?
Is your dog on heartworm medication?
If yes, what brand?
What special diet or medication is your dog on?
List any known allergies (food, drug, etc.)
What illness or surgery has your dog had before (list below, or leave empty if blank) (indicate dates)?

MonthDayYear
Date
What illness or surgery has your dog had before? (leave empty if none)
Is your dog aggressive towards other pets or people?
If yes, explain
Should be Empty: