New Client & Patient Form

New Client & Patient Form

W1915 County Road F Berlin, WI 54923 (920) 361-2101
Name*

First NameLast Name
Email
example@example.com
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How Did you Hear About Us?
Pets Name*
Breed*
Color
Date of Birth/Age*
Spayed/Neutered?
Previous Veterinary Hospital
Name of Previous Veterinary Hospital*
City & State
Phone Number*
Please note if the patient's records are under a different name(so if we need to call the previous Vet).
Please enter Diet and Feeding information. Food Brand, Amount per feeding, Frequency of feeding, Treats, Frequency and amount of treats?

Previous Vaccine History.. DOG

Previous Vaccine History.. CAT

Please upload records from previous vet...
Social Media
Do we have your permission to share a photo/story of your pet on social media?

YesNo
Third-Party Prescription Policy

We no longer approve third-party prescription request such as Chewy, Walmart Pharmacy, Allivet, PetRX and so forth. If your pet needs a medication refill, please request one during your appointment/ call the clinic and ask for a written script to send in.
Consent

I hereby authorize the veterinarian to examine, prescribe medication or treat the aforementioned pet(s). I assume responsibility for all charges incurred in the care of this animal and agree to Vetcor-Berlin Veterinary Clinic payment policy. Payment is due at the time services are rendered. We accept all major forms of credit cards (Visa, Mastercard, Discover and American Express) and cash. We are unable to offer in-house payment plans as this positions the hospital as a lending institution.
Signature

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Things to do before appointment....
Things to do before & at arrival at appointment....
Should be Empty:

Previous Veterinary Hospital