New Client/Pet Registration

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.
Work Phone
Please enter a valid phone number.
Home Phone
Please enter a valid phone number.
Email
example@example.com
Spouse/Significant Other Name

First NameLast Name
Spouse/Significant Other Cell:
Please enter a valid phone number.
Spouse/Significant Other Work
Please enter a valid phone number.
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

Clear
PLEASE SUBMIT MEDICAL RECORDS TO INFO@FAIRFIELDVH.COM
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