New Client Welcome Sheet

New Client Welcome Sheet

Please fill the following form out to the best of your ability.
New Client Form
Appointment Date*

MonthDayYear
Date
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Cell Phone Number
Please enter a valid phone number.
Home Phone Number
Please enter a valid phone number.
Which number is best to reach you?*

CellHome
Can you receive text messages?*

YesNo
Email*
example@example.com
Drivers License Number*
Drivers License State*
Spouse/Co-Owner Name

First NameLast Name
Spouse/Co-Owner Phone Number
Please enter a valid phone number.
Emergency Contact Name

First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.
Emergency Contact Relation
i.e. spouse, friend, relative, etc.
I authorize my emergency contact (other than myself) to pursue treatment if I am unavailable (your emergency contact must be an adult over the age of 18).

YesNo
Previous Veterinarian(s)
Previous Veterinarian's Phone Number
Purpose of Visit: *
Whom should we thank for referring you?
Pet Health History
Species*

CanineFeline
Pet's Name*
Sex*

FemaleMale
Spayed/Neutered?*

YesNoUnsure
Breed*
i.e. Dalmatian, German Shepherd, DSH (shorthaired cat), DLH (longhaired cat), etc.
Color*
i.e. Black/White, Tri-Color, Brown Tabby, etc.
Date of Birth/Age*
If you don't know the exact date, your best estimate is fine.
Approximate Weight*
Is your pet microchipped?*

YesNoUnsure
Does your pet have a social handle we can follow?
Diet & Environment
What food does your pet currently eat?*
Please be as specific as possible.
Amount and frequency?*
i.e. one 8 oz measuring cup twice daily, one solo cup one daily, etc.
Does your pet consume table food?*

YesNo
Is your pet primarily indoor or outdoor?*

IndoorOutdoor
Are there any other animals in the household?*

YesNo
Does your pet participate in any of the following:*

BoardingDaycareGroomingTravelingNone of the above.Other
Past History
Has your pet had any prior illnesses, accidents, or surgeries?*

YesNo
If yes, please explain.
Is your pet aggressive or fearful around strangers?*

YesNo
If yes, please explain.
Is your pet on heartworm/flea/tick prevention?*

YesNo
Please list any other medications, preventivies, and/or supplements your pet receives. *
Does your pet have any known allergies to any medications?*

YesNo
Has your pet ever had a reaction to any vaccines?*

YesNo
If yes, please explain.
Photo Consent: Do we have permission to share your pet’s image on social media, our website or other forms of related media? Your name and personal information will never be shared.*

YesNo
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 also understand that these charges will be paid at the time of release and that a deposit may be required for treatment. In the event your account is placed for collection with an outside collection agency/attorney, you will be responsible for all costs of collection not to exceed 25%, which will be added to any unpaid balance.*

I have read and agree to the above statement.
To allow for ample time for all patients and surgical procedures, Lindsay Veterinary Clinic operates primarily by appointment. We request all our clients be on time for scheduled appointments and procedures.

For your protection and that of others, pets should be properly restrained by a leash or carrier upon arrival. If your pet requires special accommodations, please give us a call when you arrive so we can assist you and your pet.

If you must cancel an appointment, we ask for 24 hours’ notice. For surgical appointments, we ask for a 48-hour cancellation notice.

We accept cash, debit, or all credit cards. We also offer Care Credit financing to help make the highest quality care accessible to all our patients.

We would be more than happy to fill your prescriptions or have your food orders ready for pick-up. Please call ahead to process refills. Please allow 24{toAllow} hours for prescription refills; special orders or controlled substances may require longer.
I have read and agree to the above statements and policies.*
Please initial.
File Upload: Add any previous records and/or a picture of your pet.

Cancelof
Signature*

Clear
Today's Date*

MonthDayYear
Date
Thank you for choosing Lindsay Veterinary Clinic! We look forward to treating your pet like a member of our Family!
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New Client Welcome Sheet

New Client Form

Pet Health History

Diet & Environment

Past History