New Client Infomation Form
Client Details:
Full Name
*
First Name
Last Name
Spouse or Friend Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Format: (000) 000-0000.
Phone Number
*
Format: (000) 000-0000.
E-mail
example@exampleName.com
Preferred method of contact:
How did you hear about us?
*
Please Select
Google
Facebook
Other
Please Specify
*
Who is authorized to make decisions for your pet(s)?
Consent
Rows
Yes
No
Photo Consent: It is ok to share your photo and/or pet(s) on social media or our website.
Treatment Consent: Authorizing the veterinarian to examine, prescribe for or treat the below-described pet(s) to the best of their abilities. I assume responsibly for all charges incurred in the care of this animal. Payment is DUE at the time of service.
Recording Consent: During patient visits, detailed information pertaining to the patient is recorded in real time using electronic health records. Do you agree to be recored for veterinary use only?
Removing Owner Consent: We will not remove someone without their consent or legal paperwork stating the first party is the sole custody owner of the pet(s).
Signature
*
Date
*
-
Month
-
Day
Year
Date
Pet's Name
Pet's Date of Birth or Age
Species
Breed
Sex
Color/Markings
Pet's Name
Pet's Date of Birth or Age
Species
Breed
Sex
Color/Markings
Submit
Should be Empty: