New Client Form

WE KNOW YOUR PET’S HEATH IS IMPORTANT AND WE THANK YOU FOR TRUSTING US TO CARE FOR THEM. TO HELP US PROVIDE THE BEST CARE POSSIBLE, PLEASE TAKE A FEW MOMENTS TO FILL OUT THIS FORM COMPLETELY. THANK YOU!
Owner's name*

First NameLast Name
Spouse/Co-Owner/Sig. Other
Cell Phone #*
Spouse/Co-Owner/Sig.Other Cell Phone Number

Area CodePhone Number
Preferred Phone Number to Contact?

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
EMAIL ADDRESS*
example@example.com
How did you hear about our clinic?

GoogleReferral from friendsSocial mediaWeChat GroupOther
If referred by friends, please enter their name so we can thank them
PET HEALTH HISTORY

Please enter details of your pet*

	Pet #1	Pet #2	Pet#3	Pet#4
Name
Breed
Age
Color
Sex (M/F)
Spayed/Neutered (Y/N)?
Previous illness/surgery list
Special diet/meds/Allergy list

AUTHORIZATION
I confirm that I am at least 18 years of age and legally authorized to make medical and financial decisions for my pet(s). I understand that any individual listed on the account, or who brings the pet in for care, is also authorized to make such decisions unless otherwise specified in writing. I hereby authorize the veterinarian to examine, prescribe for, and/or treat my pet(s). I assume full financial responsibility for all approved services and charges incurred for the care of all pets listed under my account. I understand that payment is due at the time services are rendered, and that a deposit may be required for surgical procedures or hospitalization.
Name of Previous Veterinary Clinic
Phone number of prior vet clinic
No-Call / No-Show & Late Cancellation Policy

We understand that life can be unpredictable, and sometimes plans change. However, missed appointments prevent us from helping other pets in need.

Policy:
- If you need to cancel or reschedule your appointment, please call or text us at least 6 hours before your scheduled time.
- No-call / no-show or cancellations made with less than 6 hours’ notice will require a $25 deposit to schedule your next appointment.
- This deposit will be applied toward your next visit but is non-refundable if you miss or cancel that appointment without proper notice.
Thank you for helping us provide timely care to all our patients.
SIGNATURE*

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Please Print Name*

First NameLast Name
DATE OF SIGNATURE*

MonthDayYear
Date
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PET HEALTH HISTORY

AUTHORIZATION