New Client Form
Please help us locate you in our system by providing the information below.
Client/Owner Information
Name
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Spouse/Co-Owner Name
First Name
Last Name
Spouse/Co-Owner Phone
Please enter a valid phone number.
Contact Preference
Call
Text
Email
Leave Message
How did you hear about us?
Google
Yelp
Facebook
Instagram
Sign
Harbor Website
Employee
Hospital/Vet
Friend
Other
If employee, which employee?
If hospital/vet, which?
If friend, what is their name?
Pet Information
Pet #1 Name
Species
Dog
Cat
Date of Birth Or Approximate Age
*
Breed
*
Color
Sex
Male
Female
Spayed/Neutered
Yes
No
Microchipped
Yes
No
If yes, what is the number #?
Has your pet been vaccinated?
Yes
No
If yes, where?
Does your pet have pet insurance?
Yes
No
Medical History
Allergies
Is your pet on medications? If yes, please list.
Do you have an additional pet?
Yes
No
Pet #2 Name
Species
Dog
Cat
Date of Birth Or Approximate Age
*
Breed
*
Color
Sex
Male
Female
Spayed/Neutered
Yes
No
Microchipped
Yes
No
If yes, what is the number #?
Has your pet been vaccinated?
Yes
No
If yes, where?
Does your pet have pet insurance?
Yes
No
Medical History
Allergies
Is your pet on medications? If yes, please list.
Client/Owner Authorization
I hereby authorize the veterinarian to examine, prescribe for, or treat the above-described pet(s). I assume responsibility for all charges accrued in the care of this animal presented by me or my agents. I also understand that the charges will be paid in full at the time of services rendered or at release and that a deposit may be required for surgical treatment or hospitalization. I understand that I am responsible for a returned check fee of $25. I agree to pay for the reasonable costs of collection, attorney fees, and court costs in the event that collection efforts become necessary. I grant Harbor Animal Hospital permission to use, reuse and publish any photos or videos of my pet to social media or for training purposes.
Today's Date
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Month
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Day
Year
Date
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