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
CANCELLATION POLICY: 24 hours notice required for all cancellations. I agree to a $65 fee for late cancel/no show appointments, $200 for specialist appointments, and $200 for dental/surgery cancellations Initial* for Financial Consent
All payments are due at the time of services rendered. We accept all major credit cards. Payment plans for Scratch Pay & Care Credit 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