New Client/Pet Registration

Appointment Date/Time

Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Cell Phone

Please enter a valid phone number.Format: (000) 000-0000.

Work Phone

Please enter a valid phone number.Format: (000) 000-0000.

Home Phone

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

Spouse/Significant Other Name

First NameLast Name

Spouse/Significant Other Cell:

Please enter a valid phone number.Format: (000) 000-0000.

Spouse/Significant Other Work

Please enter a valid phone number.Format: (000) 000-0000.

Spouse/Significant Other Email

example@example.com

Best Contact Number

How were your referred to our clinic?

Family/FriendInternetDoctor ReferralOther

Please let us know if a client referred you so we may thank them!

Previous hospital

Pet's Name:

Species:

DogCatOther

Color:

Date of Birth/Age:

Sex:

MaleFemale

Has your pet been spayed or neutered?

YesNo

Microchip

How long have you owned your pet?

Where did you acquire your pet?

Food or Drug Allergies

Current Medication

Medical History/Prior Illness/Surgery

I give permission for photos and videos of my pet to be used in all forms of social media of Fairfield Veterinary Hospital

YesNo

I hereby authorize the veterinarian to examine, prescribed for, or treat the above described animal. I also understand that these charges will be paid for at the time services are rendered.

Signature

PLEASE SUBMIT MEDICAL RECORDS TO INFO@FAIRFIELDVH.COM