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

Family/FriendInternetDoctor ReferralOther

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

Previous hospital

Pet's Name:

DogCatOther

Color:

Date of Birth/Age:

MaleFemale

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

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