New Client Welcome Form

New Client Welcome Form
Thank you for giving us the opportunity to care for your pet. Please help us meet your needs better by taking a moment to share important information we will need as we support your pet’s needs today and in the future.
Primary Caregiver*

First NameLast Name
Secondary Caregiver

First NameLast Name
I Authorize or do not authorize the secondary caregiver to make all medical decisions about my pet including but not limited to: surgery or euthanasia.
Physical Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Select Location*
Home Phone
Please enter a valid phone number.
Cell Phone*
Please enter a valid phone number.
Work Phone*
Please enter a valid phone number.
Employer
Spouse Employer
Phone
Please enter a valid phone number.
Email*
example@example.com
Previous Veterinarian
Name*
Phone
Please enter a valid phone number.
We love social media and occasionally we will have pictures to post that may include you,
members of your family, and/or your pet(s). Check here if you would like us to make you and your pet(s) a star of CHAH or Here if you and/or your pet is shy
We will gladly prepare a written estimate if you desire. This will be important to you since ALL PROFESSIONAL FEES ARE DUE AT THE TIME SERVICES ARE RENDERED. In cases of extensive or surgical procedures, when full payment may be difficult at discharge, we take all major credit cards and Care Credit in advance of treatment. Although we are unable to accept checks on the first visit there will be a $30.00 service charge for any check returned unpaid.

To prevent the spread of infectious diseases, all hospitalized and boarded patients must be current on all vaccines and free from internal and external parasites. The signature below authorizes this level of preventative care and appropriate charges will be assessed on the discharge invoice.
How/why did you select us?*

Phone bookNewspaper adRadio adDrive byFacebookReferral by a friendInternet searchReferral by another veterinarianOther
Referral by a friend (Name)
Name
Internet search (which one)
Referral by another veterinarian
Pet Information
Name*
Species/Breed*
Date of Birth*

MonthDayYear
Sex*
Spayed or Neutered*
Color*
Have you or your pets traveled outside of the area?

YesNo
When?
Would you like to add another pet?

YesNo
Pet Information #2
Name*
Species/Breed*
Date of Birth*

MonthDayYear
Sex*
Spayed or Neutered*
Color*
Have you or your pets traveled outside of the area?

YesNo
When?
Would you like to add another pet?

YesNo
Pet Information #3
Name*
Species/Breed*
Date of Birth*

MonthDayYear
Sex*
Spayed or Neutered*
Color*
Have you or your pets traveled outside of the area?

YesNo
When?
Would you like to add another pet?

YesNo
Pet Information #4
Name*
Species/Breed*
Date of Birth*

MonthDayYear
Sex*
Spayed or Neutered*
Color*
Have you or your pets traveled outside of the area?

YesNo
When?
Should be Empty:

New Client Welcome Form

Previous Veterinarian

Pet Information

Pet Information #2

Pet Information #3

Pet Information #4