Benson Animal Clinic New Client Form

New Client Form

Welcome to Benson Animal Clinic! Please fill out the form to register as a new client.
Client Information
Full Name*

First NameLast Name
Email Address
example@example.com
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Pet Information

Please fill out all information to the best of your ability
Pet's Name*
Type of Pet*

DogCat
Breed/Type:
Please include pet breed/type, color, and any other identifying information.
Age:
Gender*

Male IntactMale NeuteredFemale IntactFemale Spayed
Is your pet known to be aggressive/reactive towards other people and/or pets?

Yes, my pet is reactive towards other animals.Yes, my pet is reactive towards other people.Yes, my pet is reactive towards other people and pets.No, my pet has no known history of aggression or reactivity.
If your pet is known to be reactive, we can ensure that our lobby is cleared and you and your pet will be placed in a room immediately. If your dog requires a muzzle, we will provide one for you.
Medical History
Please provide any relevant medical history for your pet.
Previous Veterinary Records

Please be sure to attach any Previous Veterinary Clinic Information and Vaccinations here.
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Medical Conditions
Reason for Visit*
Click here to add an additional pet:

Add Additional Pet
Additional Pet Information

Please fill out all information to the best of your ability
Pet's Name*
Type of Pet*

DogCat
Breed/Type:
Please include pet breed/type, color, and any other identifying information.
Age:
Gender*

Male IntactMale NeuteredFemale IntactFemale Spayed
Medical History
Please provide any relevant medical history for your pet.
Previous Veterinary Records

Please be sure to attach any Previous Veterinary Clinic Information and Vaccinations here.
Cancelof
Medical Conditions
Reason for Visit*
Previous Veterinary Clinic:
Please add your pet's previous veterinary clinic information. If unknown leave blank.
Additional Comments
Date

MonthDayYear
Date
**ALL PAYMENTS ARE DUE AT THE TIME OF SERVICES, WE ACCEPT ALL MAJOR CREDIT CARDS, CARE CREDIT, SCRATCH PAY, CHECK, AND CASH**
Should be Empty:

New Client Form

Client Information

Pet Information

Additional Pet Information