New Client Form

Thank you for joining Whisker Wellness Center in our mission to help cats live extraordinary lives with their families. Please complete this form prior to your initial appointment to streamline your check-in so we can get straight to getting to know you and your kitty.

Name*

First NameLast Name

Email*

example@example.com

Primary Phone*

MobileLandline

Secondary Phone

MobileLandline

Address

Street Address

Street Address Line 2

CityState

Zip Code

Preferred Method of Contact*

EmailPhonePostal Mail

Spouse/Co-Owner Name

First NameLast Name

Spouse/Co-Owner Phone

MobileLandline

How did you find out about our hospital? If you were referred by someone, who should we thank?*

Cat's Name #1*

Breed*

Age/Date of Birth*

Color*

Sex*

Does your cat have a microchip identification?*

YesNo

Previous veterinarian information:

Did your cat have any previous medical problems?

Is your cat currently on any medication?

Do you have any more cats?*

YesNo

Cat's Name #2*

Breed*

Age/Date of Birth*

Color*

Sex*

Does your cat have a microchip identification?*

YesNo

Previous veterinarian information:

Did your cat have any previous medical problems?

Is your cat currently on any medication?

I give permission for Whisker Wellness Center to share photographs or case specific information about my cat in all media.*

YesNo

Upload here

I, the undersigned, do hereby certify that I am 18 years of age or older and the owner, or assuming responsibility, financial or otherwise, for the above-described cat(s). I authorize Whisker Wellness Center to examine, prescribe for or treat the cat(s). I assume responsibility for all charges incurred in the care of this cat. I understand these charges must be paid at the time of service and that a deposit may be required for treatment. Accepted payment methods include Visa, MasterCard, Discover, American Express, and Scratch Pay.I understand that Whisker Wellness Center requires 24 hours notice for all appointment cancellations or reschedules. Canceling/rescheduling without 24 hour notice or missing my appointment will result in a missed appointment fee which must be paid prior to scheduling any future appointments.

Date*

Signature

New Client Form

Cat Information