New Client Patient Form

New Client Patient Form
Owner’s Information
Pet Owner’s Name*

First NameLast Name
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Preferred Phone
Alternate Phone
Email Address*
example@example.com
Emergency Contact Name & Phone
Driver’s License
Date of Birth

MonthDayYear
How did you hear about us? Please circle one. Website, Directory Plus, Annie’s Orphans, Humane Society, Cat Care TNR, Action Pages, Location, or Client Referral Type a label
Pet Information
Pet’s Name
Breed
Birthdate
Color
Female Spayed?

YesNo
Male Neutered

YesNo
Medical Conditions
(allergies, drug reactions, heart problems, etc)
Behavioral Concerns
(house breaking, aggression, destructive behavior, etc)
Has your Pet traveled/lived in areas besides Durango?

YesNo
Where
Vaccination/Exam History
(indicate dates if possible-if you have records with you, please inform the receptionist)
Heartworm and/or Flea & Tick Prevention
Is your pet currently on Heartworm Prevention?

YesNo
Brand
Are you currently using a Flea & Tick Prevention?

YesNo
Brand
Nutrition
Dry food Brand
Canned
Supplements (glucosamine, herbs, vitamin, etc)
Dental Care
Do you brush your pet’s teeth?

YesNo
Date of last dental cleaning?

MonthDayYear
We will gladly obtain your pets previous history and records from another Veterinarian office, please provide their name and phone number
Add Another Pet?*

YesNo
Pet’s Name
Breed
Birthdate
Color
Female Spayed?

YesNo
Male Neutered

YesNo
Medical Conditions
(allergies, drug reactions, heart problems, etc)
Behavioral Concerns
(house breaking, aggression, destructive behavior, etc)
Has your Pet traveled/lived in areas besides Durango?

YesNo
Where
Vaccination/Exam History
(indicate dates if possible-if you have records with you, please inform the receptionist)
Heartworm and/or Flea & Tick Prevention
Is your pet currently on Heartworm Prevention?

YesNo
Brand
Are you currently using a Flea & Tick Prevention?

YesNo
Brand
Nutrition
Dry food Brand
Canned
Supplements (glucosamine, herbs, vitamin, etc)
Dental Care
Do you brush your pet’s teeth?

YesNo
Date of last dental cleaning?

MonthDayYear
We will gladly obtain your pets previous history and records from another Veterinarian office, please provide their name and phone number
All fees are Due and Payable at the time of service.

Please let our front desk know if an estimate is needed and we will gladly prepare one for you.
Date*

MonthDayYear
Date
Signature

There will be a $25.00 fee for any returned checks and/or missed appointments. Clear
Should be Empty:

New Client Patient Form

Owner’s Information

Pet Information

Heartworm and/or Flea & Tick Prevention

Nutrition

Dental Care

Heartworm and/or Flea & Tick Prevention

Nutrition

Dental Care