PAWS Veterinary Center New Client Form

PAWS Veterinary Center New Client Form
Customer Details:
Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
E-mail
example@example.com
How did you hear about us?*
Pet's Name
Pet Species

DogCat
Sex

MaleFemale
Breed
Color/Markings
Date of Birth or Approximate Age
Neutered/Spayed

Neutered/SpayedNot Neutered/Spayed
Is your pet aggressive?

Yes (We are still able to treat aggressive pets but our staff MUST know this in advance)No
Microchip Number (if applicable)
Primary Care Veterinarian & Phone Number (if transferring care)
Current Medications (Please list Medication Name, Dosage and Frequency)
Current Medical Conditions (Please list the condition/diagnosis and treatment)
Previous Surgical Procedures (Please list the Procedure and Date)
Does your pet have any allergies?

YesNo
If Yes, please list the allergy below:
Is there anything else we should know about your pet?
Authorization:

I authorize Paws Veterinary Center to provide medical care to my pet as deemed necessary by the attending veterinarian. I agree to pay for all services rendered at the time of the visit, unless prior arrangements have been made.
Signature

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