Client Information Form

Client Information Form
Today's Date*

MonthDayYear
In order to reduce the risk of exposure to COVID-19 for the staff and the other clients, we are asking that clients who are ill reschedule their appointment, or have another person bring in their pet. In the event that the visit is an emergency, and no other person is able to bring in pet, we are asking that the client inform our staff (over the phone) of the illness before interacting with them, so they can utilize additional safety protocols. ***I confirm that I am not experiencing any illness that could be related to a COVID-19 infection. *
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Owner's Name*
Email Address
example@example.com
Address*

Street Address

Apartment

CityState / Province

Postal / Zip Code
Driver's License Number *
Social Security Number (If using checks)
Primary Phone Number
Is the above number a cell phone, home phone, or work phone?

Cell phoneHome phoneWork phone
Secondary Phone Number
Is the above number a cell phone, home phone, or work phone?

Cell phoneHome phoneWork phone
Additional Owner
Additional Owner's Phone Number
Is the above number a cell phone, home phone, or work phone?

Cell phoneHome phoneWork phone
Your Date of Birth

MonthDayYear
Employer or Occupation
How would you like to receive reminders?*

Text/AppEmailMailed to addressNo reminders
Who is your current Veterinarian?*
Emergency Clients: It is our policy to provide records to your regular veterinarian so that follow-up care may be provided. If you do not wish to have records provided to your regular vet, please initial below, and advise our staff directly.
Have you ever been a client here before?

YesNo
If so, please provide the name you used for your account.
Do you request a particular doctor?

YesNo
If yes, please describe
Did you hear about us from another client? If so, please list them so we can thank them! If not, please list how you heard about us.

Patient Information*

	Not Satisfied
Your Pet's Name
Species (Canine/Feline/Exotic Species)
Breed (best guess, if mixed- please say what they are mixed with)
Date of Birth (or estimated age)
Color
Sex
Spayed or Neutered?

Additional Patient Information

	Pet #2	Pet #3	Pet #4
Your Pet's Name
Species
Breed (best guess)
Date of Birth
Color
Sex
Spayed or Neutered?

Please write any pertinent history for your pet(s). Provide date of last veterinary visit, including vaccinations and testing if applicable. Include a brief reason for your current visit.
An itemized treatment plan with fees will be provided for you at the time of your pet's exam. Full payment of this plan will be required at this time. PLEASE NOTE THAT WE REQUIRE FULL PAYMENT OF ALL TREATMENT COSTS AT THE TIME SERVICES ARE RENDERED. *
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This visit will be paid in

CashLocal CheckCareCreditCredit/Debit CardOther
Signature (use mouse or finger to sign)

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Northwood Animal Hospital ▪ 1881-B N. Martin Luther King Jr. Blvd. Tallahassee, FL 32303

T: (850) 385-8181 ▪ F: (850) 385-3501

www.NorthwoodAnimalHospital.com
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