New Patient Registration Form

New Patient Registration Form
Please fill out this form with basic information for you and your pet(s)
Client Information
Your Name*

First NameLast Name
Your Phone Number*
Please enter a valid phone number.
Your Email*
example@example.com
Your Birthday*

MonthDayYear
(For calling medicine into any Pharmacy)
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Alternate Contact Name

First NameLast Name
Alternate Contact Phone Number
Please enter a valid phone number.
Alternate Contact Email
example@example.com
How did you hear about us?*
Pet Information
Pet #1 Species/Gender
Pet #1 Name*
Pet #1 Age / DOB*

MonthDayYear
Pet #1 Species/Gender*
Pet #1 Breed*
Pet #1 Microchip Number*
Pet #1 Color / Marking*
Pet #1 Medical Conditions (allergies, drug reactions, heart conditions, etc)
Pet #1 Current Medications
Pet #1 How does your pet normally react at the vet?
Pet #1 How does your pet normally react to meeting new people?
Pet #1 Has your pet ever bitten someone or attempted to bite someone?

NoYes
If yes, please explain
Pet #1 Vaccination History
Date*

MonthDayYear
Pet #1 Vaccination History (indicate the date (month/year) your pet received the following vaccinations.)*

RabiesCanine Distemper / Parvo (DHPP)BordetellaLeptoLymeFeline Distemper (FVRCP)Feline Leukemia
Pet #1 Vaccination History (indicate the date (month/year) your pet received the following vaccinations.)
Rabies

MonthDayYear
Date
Canine Distemper / Parvo (DHPP)

MonthDayYear
Date
Bordetella

MonthDayYear
Lepto

MonthDayYear
Date
Lyme

MonthDayYear
Date
Feline Distemper (FVRCP)

MonthDayYear
Date
Feline Leukemia

MonthDayYear
Date
Pet #1 Nutrition*

Dry BrandCanned Brand
Pet #1 Nutrition (indicate the type of wet food and/or dry food regularly fed)*
Table Scraps?*

YesNo
Pet #1 Dental Care
Do you brush your pet's teeth? *

YesNo
Date of last dental cleaning?*

MonthDayYear
Pet #1 Heartworm Preventative
Is your pet currently taking heartworm preventative? *

YesNo
If yes, what kind:
Pet #1 Microchip Identification*
Add Another Pet?*

YesNo
Pet #2
Pet #2 Name
Pet #2 Age / DOB

MonthDayYear
Pet #2 Species/Gender
Pet #2 Breed
Pet #2 Microchip Number
Pet #2 Color / Marking
Pet #2 Medical Conditions (allergies, drug reactions, heart conditions, etc)
Pet #2 Current Medications
Pet #2 How does your pet normally react at the vet?
Pet #2 How does your pet normally react to meeting new people?
Pet #2 Has your pet ever bitten someone or attempted to bite someone?

NoYes
If yes, please explain
Pet #2 Vaccination History
Date*

MonthDayYear
Pet #2 Vaccination History ((indicate the date (month/year) your pet received the following vaccinations.)*

RabiesCanine Distemper / Parvo (DHPP)BordetellaLeptoLymeFeline Distemper (FVRCP)Feline Leukemia
Pet #2 Vaccination History ((indicate the date (month/year) your pet received the following vaccinations.)
Rabies

MonthDayYear
Date
Canine Distemper / Parvo (DHPP)

MonthDayYear
Date
Bordetella

MonthDayYear
Date
Lepto

MonthDayYear
Date
Lyme

MonthDayYear
Date
Feline Distemper (FVRCP)

MonthDayYear
Date
Feline Leukemia

MonthDayYear
Date
Pet #2 Nutrition*

Dry BrandCanned Brand
Pet #2 Nutrition (indicate the type of wet food and/or dry food regularly fed)*
Table Scraps?*

YesNo
Pet #2 Dental Care
Do you brush your pet's teeth? *

YesNo
Date of last dental cleaning?*

MonthDayYear
Pet #2 Heartworm Preventative
Is your pet currently taking heartworm preventative? *

YesNo
If yes, what kind:
Pet #2 Microchip Identification*
Add Another Pet?*

YesNo
Pet #3
Pet #3 Name
Pet #3 Age / DOB

MonthDayYear
Pet #3 Species/Gender
Pet #3 Breed
Pet #3 Microchip Number
Pet #3 Color / Marking
Pet #3 Medical Conditions (allergies, drug reactions, heart conditions, etc)
Pet #3 Current Medications
Pet #3 How does your pet normally react at the vet?
Pet #3 How does your pet normally react to meeting new people?
Pet #3 Has your pet ever bitten someone or attempted to bite someone?

NoYes
If yes, please explain
Pet #3 Vaccination History
Date*

MonthDayYear
Vaccination History

RabiesCanine Distemper / Parvo (DHPP)BordetellaLeptoLymeFeline Distemper (FVRCP)Feline Leukemia
Pet #3 Vaccination History ((indicate the date (month/year) your pet received the following vaccinations.)
Rabies

MonthDayYear
Date
Canine Distemper / Parvo (DHPP)

MonthDayYear
Date
Bordetella

MonthDayYear
Date
Lepto

MonthDayYear
Date
Lyme

MonthDayYear
Date
Feline Distemper (FVRCP)

MonthDayYear
Date
Feline Leukemia

MonthDayYear
Date
Pet #3 Nutrition*

Dry BrandCanned Brand
Pet #3 Nutrition (indicate the type of wet food and/or dry food regularly fed)*
Table Scraps?*

YesNo
Pet #3 Dental Care
Do you brush your pet's teeth? *

YesNo
Date of last dental cleaning?*

MonthDayYear
Pet #3 Heartworm Preventative
Is your pet currently taking heartworm preventative? *

YesNo
If yes, what kind:
Pet #3 Microchip Identification*
May we contact your previous veterinarian for records?*

YesNo
Previous veterinarian
We LOVE pets on social media! Do you authorize Valley Center Veterinary Clinic, its representatives and employees the right to take photographs of me and/or my pet, and to copyright, and use/publish for any lawful purpose, including web content and advertising.*

YesNo
APPOINTMENT RESERVATION FEE: All clients new to Valley Center Veterinary Clinic are required to pay a $68 appointment reservation fee to reserve their pet(s) first appointment. This fee will be applied to the final invoice balance. Should the final invoice be less than the fee paid, the difference will be refunded. I agree to pay this fee and assume financial responsibility for the balance of all services rendered at the time the pet is discharged from the hospital.
Initial for Financial Consent*
CANCELLATION POLICY: 24 hours notice required for all cancellations. If I do not cancel or reschedule at least 24 hours prior to my appointment, I agree that my $68 Appointment Reservation Fee will be FORFEITED.
Initial for Financial Consent*
All payments are due at the time of services rendered. We accept all major credit cards. Payment plans for Care Credit, Scratch Pay, All Pet Card & Varidi can be approved in as little as 10 minutes and are subject to limitations. I have read and understand the above statements and agree to all terms therein.
Date*

MonthDayYear
Signature*

Clear
Should be Empty:

New Patient Registration Form

Client Information

Pet Information

Pet #1 Vaccination History

Pet #1 Dental Care

Pet #1 Heartworm Preventative

Pet #2 Vaccination History

Pet #2 Dental Care

Pet #2 Heartworm Preventative

Pet #3 Vaccination History

Pet #3 Dental Care

Pet #3 Heartworm Preventative