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
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Email
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Primary Phone
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Home Phone
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Work Phone
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Emergency Contact Info
First Name
Last Name
Phone Number
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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.
Previous Veterinary Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Photo of Pet
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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
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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
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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).
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No
Signature
Date
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Month
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Day
Year
Date
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