Bailey Caring Mobile Vet New Client Form

NEW CUSTOMER FORM

Bailey Caring Mobile Vet

Thank you for giving me the opportunity to care for your pet(s). So that we may become better acquainted, please complete the following:

Date*

Date

Name*

First NameLast Name

Spouse/Co-Owner’s Name

First NameLast Name

Email

You best contact email

Phone Number*

Area CodePhone Number

Work Phone

Area CodePhone Number

Spouse / Co-Owner's Phone

Area CodePhone Number

Address*

Street Address

Street Address Line 2

CityState

Zip Code

Accepted payment methods: Cash, Venmo, or Zelle.*

CashZelleVenmo

How did you become aware of our clinic?

Whom may we thank if a friend gave you a recommendation for us?

Did a client recommend us to you?

Yes, I would like to receive email about special offers and updates

YesNo

I give permission to use my pet(s)’ picture for advertising purposes or on social media.

YesNo

Legal Acknowledgment*

I understand that every effort will be made to achieve a successful outcome and to provide for all safety in hospital care and handling. In an emergency, all necessary medical services will be provided to maintain the patient's health unless otherwise stated by the owner. I authorize this hospital to receive, prescribe for, and treat the pet(s) listed below. Furthermore, I agree to pay all fees for all services rendered when the pet is discharged from the hospital. I understand that veterinary service is provided during nighttime hours as necessary in the judgment of the veterinarian in charge.

Electronic signature*

Name of person responsible for the pet(s) care

Date*

Date

Who can we contact to get previous records?

Name of clinic for your pets records

Pet #1

Your Pets Name and Date of Birth*

Pets name and date of birth

Breed and Color*

Pets breed and color

What service does your pet need?*

How can I help?

Sex*

MaleFemaleNeutered MaleSpayed Female

Our Pet is:*

IndoorsOutdoorsEqually Indoors / Outdoors

Any previous serious illnesses or surgeries? *

Any previous serious illnesses or surgeries?

Any allergies to vaccinations or medications? *

Any allergies to vaccinations or medications?

Is your pet on any special diets or medications? *

Is your pet on any special diets or medications?

Is Your Pet Aggressive? Yes/No If yes, please explain:*

Is Your Pet Aggressive? Yes/No If yes, please explain:

If you have just one pet select submit now.

If you have more than one pet, keep going below.

Pet #2

# 2 Pet - Name and Date of Birth

Pets name and date of birth

What service does your pet need?

How can I help?

Breed and Color

Pets breed and color

Sex

MaleFemaleNeutered MaleSpayed Female

Our Pet is:

IndoorsOutdoorsEqually Indoors / Outdoors

Any previous serious illnesses or surgeries?

Any allergies to vaccinations or medications?

Is your pet on any special diets or medications?

Is Your Pet Aggressive? Yes/No If yes, please explain:

If you have more than 2 pets keep going below.

Pet #3

# 3 Pet - Name and Date of Birth

Pets name and date of birth

What service does your pet need?

How can I help?

Breed and Color

Pets breed and color

Sex

MaleFemaleNeutered MaleSpayed Female

Our Pet is:

IndoorsOutdoorsEqually Indoors / Outdoors

Any previous serious illnesses or surgeries?

Any allergies to vaccinations or medications?

Is your pet on any special diets or medications?

Is Your Pet Aggressive? Yes/No If yes, please explain: