Mt. Washington Animal Clinic
New Client Form
Client Name
*
First Name
Last Name
Additional person on account (i.e. spouse, significant other, parent)
First Name
Last Name
Email
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary phone number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Secondary Phone number
Please enter a valid phone number.
Format: (000) 000-0000.
How did you hear about our clinic?
Friend/Family
Facebook
Google
Phonebook
Other
Do you have a doctor you prefer to see?
Dr. Albert
Dr. Carnes
No preference
Public health information: Please check all that apply
Children in the household
Person in the home is immunocompromised (chemotherapy, transplant, etc)
Pregnancy in the household
Pet used for therapy (taken to nursing homes) or is a service animal
I authorize Mt Washington Animal Clinic to use pictures of my pet for market purposes, including but not limited to use on the website or facebook page:
Please Select
Yes
No
I assume full responsibility for all charges incurred and I understand that a deposit may be required for hospitalization and/or treatment. I understand all professional fees are due at the time services are rendered and agree to pay for services.
Pet Name
*
Species
Please Select
Dog
Cat
Breed
Color
Birthday/Age
How long have you owned this pet?
Sex
Male
Female
Male neutered
Female spayed
Is this pet microchipped?
Yes
No
Microchip number?
Current food?
How much do you feed them a day?
Date last vaccines given? (its ok to estimate)
Has this pet ever had a vaccine reaction?
Yes
No
What, if any, heartworm and/or flea and tick prevention is your pet on?
Please list any known medical conditions (e.g. Cushing's Disease, Diabetes, Addison's Disease, glaucoma, dry eye, pancreatitis, kidney disease, liver disease, etc.)
Is your pet on any medications? (please list medication and dose)
I have multiple pets to add to my account
*
Yes
No
Pet #2
Pet #3
Pet #4
Pet #5
Continue
Continue
Should be Empty: