Veterinary New Client Form

We know your pet's health is important and we thank you for trusting us to care for them. To help us provide the best care possible, please take a few moments to fill out this form completely. Thank you!
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*
Can we communicate with you at this number by text?

YesNo
Additional Phone Number
Email Address*
example@example.com
Spouse/Partner/Co-Owner (if applicable)
Spouse/Partner/Co-Owner (if applicable) CELL PHONE
Spouse/Partner/Co-Owner (if applicable) Email Address
PET HEALTH HISTORY
Name of Pet*
Species*

DogCatOther
Sex*

Male IntactMale NeuteredFemale IntactFemale Spayed
Breed*
Color*
Birth Date or Age*
Previous Vet Clinic - please have medical records sent to drnancy@moscowvetonthego.com
please type N/A if not applicable
Reason for Visit*
How are your pets with strangers at the house?*

Loves everybody!ScaredShyAggressiveOther
Does your pet have a microchip identification?*

YesNoUnknown
Any treats off limits, or any dietary issues?
Anything else we should know?
May we post photos of your pet to our social media pages?

YesNo
Do you have a second pet?
SECOND PET HEALTH HISTORY
Name of Pet*
Species*

DogCatOther
Sex*

Male IntactMale NeuteredFemale IntactFemale Spayed
Breed*
Color*
Birth Date or Age*
Previous Vet Clinic - please have medical records sent to drnancy@moscowvetonthego.com
please type N/A if not applicable
Reason for Visit*
How are your pets with strangers at the house?*

Loves everybody!ScaredShyAggressiveOther
Does your pet have a microchip identification?*

YesNoUnknown
Any treats off limits, or any dietary issues?
Anything else we should know?
May we post photos of your pet to our social media pages?

YesNo
How did you find out about us? If you were referred by someone, who should we thank?
AUTHORIZATION
I hereby authorize the veterinarian to examine, prescribe for, and/or treat my pets. I understand that payment is due in full at the time that services are performed. We accept all major credit cards, check, or cash. We neither extend credit nor bill for services.
Click Here to View Moscow Vet on the Go Policies
I have read and agree to Vet on the Go’s Veterinary Care Policies.
SIGNATURE*

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DATE OF SIGNATURE*

MonthDayYear
Date
Should be Empty:

PET HEALTH HISTORY

SECOND PET HEALTH HISTORY

AUTHORIZATION

Click Here to View Moscow Vet on the Go Policies