Palmetto Animal Hospital - New Client Form

New Client Form

Welcome to Palmetto Animal Hospital. Thank you for allowing us to care for your pet. We'll be happy to answer any questions you have about your pet's health. Please take this time to fill in this form completely.
Client Information
Owner Name*

First NameLast Name
Spouse Name

First NameLast Name
E-mail*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home #
Please enter a valid phone number.
Cell #*
Please enter a valid phone number.
Emergency #*
Please enter a valid phone number.
Employer Name
Work #
Please enter a valid phone number.
Spouse Employer
Spouse Work #
Please enter a valid phone number.
How Did You Hear About Us?*

Drove/Walked ByPhone BookInternetYelpNew Mover Mailer/PostcardClientEmployeeOther Hospital/DoctorOther
If client/employee/other hospital/doctor, who can we thank?*
Pet Information
Pet Name*
Date of Birth*
Type a question*

DogCat
Gender*

MaleFemale
Spayed/Neutered*

YesNo
Breed*
Color*
Do you have more than one pet?*

NoYes
Pet Information #2
Pet Name*
Date of Birth*
Species*

DogCat
Gender*

MaleFemale
Spayed/Neutered*

YesNo
Breed*
Color*
Do you have more than two pets?*

NoYes
Pet Information #3
Pet Name*
Date of Birth*
Species*

DogCat
Gender*

MaleFemale
Spayed/Neutered*

YesNo
Breed*
Color*
Vaccination History

Please provide the name and number of the veterinary clinic for us to obtain your pet's history. If you have records, please provide them as soon as possible to get your pet(s) up to date in the system.
Hospital Name
Hospital Phone #
Please enter a valid phone number.
Hospital Policy
Check Policy: We apologize for any inconvenience, but checks are not accepted for new clients that have a balance that exceeds the amount of $200.00. Payment of such amounts must be paid by cash or credit card. All payments are rendered at the time of services. A deposit of half is also required in the event of a hospitalized pet. The remainder of the balance is to be paid in full at the time of discharge.
I have read and understood the policies explained above.
Signature*

Clear
Today's Date*

MonthDayYear
Date
Should be Empty:

New Client Form

Client Information

Pet Information

Pet Information #2

Pet Information #3

Vaccination History

Hospital Policy