Pound Ridge Veterinary - Client Information Form

Client Information Form

Thank you for allowing us to care for your pet. Please help us to better meet your needs by taking a moment to complete this information sheet.
Client Information
Today's Date*

MonthDayYear
Date
Owner's Name*

First NameLast Name
Spose/Co-Owner

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone*
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
In care of an EMERGENCY, please call*
Emergency Contact Phone #*
How did you hear about us?*

GoogleFacebookHospital SignOther InternetExisting ClientCurrent EmployeeOther Hospital/DoctorOther
If existing client/current employee, other hospital/doctor, who can we thank?*
Pet's Information
Pet Name*
Species*

DogCatOther
Breed*
Color/Description*
Age (Years)*
Date of Birth (if known)
Sex*

MaleFemale
Altered or Spayed*

YesNo
Diet (Brand of Food)*
Prior Illness. Please provide details.
Prior Surgeries. Please provide details.
Have you sent us your pet's medical history yet?*

YesNo
Please email a copy of your pet's records to poundridgevet@gmail.com or by fax to 917-764-4202. Alternatively, please provide us with the name of the hospital we can contact to get it. *
Do you have another pet with you today?*

NoYes
Pet's Information - Pet #2
Pet's Name*
Species*

DogCatOther
Breed*
Color/Description*
Age (Years)*
Date of Birth (If Known)
Sex*

MaleFemale
Altered or Spayed*

YesNo
Diet (Brand of Food)*
Prior Illness. Please provide details.
Prior Surgeries. Please provide details.
Have you sent us your pet's medical history yet?*

YesNo
Please email a copy of your pet's records to poundridgevet@gmail.com or by fax to 917-764-4202. Alternatively, please provide us with the name of the hospital we can contact to get it. *
Do you have another pet with you today?*

NoYes
Pet's Information - Pet #3
Pet's Name*
Species*

DogCatOther
Breed*
Color/Description*
Age (Years)*
Date of Birth (If Known)
Sex*

MaleFemale
Altered or Spayed*

YesNo
Diet (Brand of Food)*
Prior Illness. Please provide details.
Prior Surgeries. Please provide details.
Have you sent us your pet's medical history yet?*

YesNo
Please email a copy of your pet's records to poundridgevet@gmail.com or by fax to 917-764-4202. Alternatively, please provide us with the name of the hospital we can contact to get it. *
Payment:

We accept cash, checks, all major credit cards, and CareCredit for your convenience. We are in compliance with the "Red Flags" rule passed by the FTC to ensure your identity and privacy are secure.
If you would like to leave your credit card on file as a convenience for future use, please initial here and inform the receptionist. *
I understand that I may receive a written fee estimate if I request one and that a final fee will be based on actual services rendered. Payment is due as services are rendered. For hospitalized cases, a deposit is required in advance. The balance is due upon discharge from the hospital. In the event payment is not made at the time of service, it is our policy to apply a service charge to accounts with a balance over 30 days old. All returned checks will incur a charge of $35.00. In the event the account is referred for collection, balances owed will be subject to additional annual interest charges of 16%.*
Today's Date*

MonthDayYear
Date
Should be Empty:

Client Information Form

Client Information

Pet's Information

Pet's Information - Pet #2

Pet's Information - Pet #3

Payment: