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!
Name
*
First Name
Middle Name
Last Name
Spouse/Partner's Name
First Name
Middle Name
Last Name
Physical Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mailing Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Phone Number
*
Please enter a valid phone number.
Spouse/Partner Phone Number
Please enter a valid phone number.
Alternate Phone Number
Please enter a valid phone number.
Email (write none if you do not use email)
*
example@example.com
How did you learn about our hospital?
PET HEALTH HISTORY
PET NAME
*
TYPE OF PET
*
DOG
CAT
OTHER
SEX
*
MALE INTACT
MALE NEUTERED
FEMALE INTACT
FEMALE SPAYED
BREED
*
COLOR
*
BIRTH DATE OR AGE
*
VACCINE HISTORY
CURRENT MEDICATIONS/PREVENTATIVES
SIGNIFICANT MEDICAL HISTORY, ALLERGIES, DIETARY
REASON FOR VISIT
*
~~FOR ADDITIONAL PETS, PLEASE FILL OUT A NEW PATIENT FORM ON WEBSITE~~
AUTHORIZATION
*
I HEREBY AUTHORIZE THE VETERINARIAN TO EXAMINE, PRESCRIBE FOR, AND/OR TREAT MY PETS. I ASSUME FULL RESPONSIBILITY FOR ALL CHARGES INCURRED FOR THE CARE OF ALL MY PETS ON MY FILE. I ALSO UNDERSTAND THAT THESE CHARGES WILL BE PAID AT THE TIME OF SERVICE AND THAT A DEPOSIT MAY BE REQUIRED FOR SURGICAL TREATMENT OR HOSPITALIZATION.
SIGNATURE
*
DATE OF SIGNATURE
*
-
Month
-
Day
Year
Date
Submit
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