Dr. Fitz’s Bayside Animal Clinic
New Client/Patient Form
Owner's Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Email
example@example.com
Primary Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Home Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Work Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact Info
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
PET INFORMATION
Pet Name
Species
Dog
Cat
Breed
Date of Birth or Age
Color/Description
Sex
Male
Neutered
Female
Spayed
Has your pet had previous veterinary care?
Yes
No
Previous Veterinary Name
First Name
Last Name
Previous Veterinary Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Previous Veterinary Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Photo of Pet
Browse Files
Drag and drop files here
Choose a file
Cancel
of
I have another pet
Yes
No
Pet Name #2
Species
Dog
Cat
Breed
Date of Birth or Age
Color/Description
Sex
Male
Neutered
Female
Spayed
Photo of Pet
Browse Files
Drag and drop files here
Choose a file
Cancel
of
I have another pet
Yes
No
Pet Name #3
Species
Dog
Cat
Breed
Date of Birth or Age
Color/Description
Sex
Male
Neutered
Female
Spayed
Photo of Pet
Browse Files
Drag and drop files here
Choose a file
Cancel
of
I authorize Dr. Fitz’s Bayside Animal Clinic to use photographs or video clips taken of my pet(s) for educational purposes, including print, internet and all other forms of media (no personal information will be disclosed).
Yes
No
Signature
Date
-
Month
-
Day
Year
Date
Submit
Should be Empty: