New Client Form
Client Information - Please fill out completely
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First & Last Name:
Significant Other's First & Last name:
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[Approval granted until otherwise withdrawn in writing]
Primary Phone:
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Please enter a valid phone number.
What type of phone number is this?
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Cell Phone
Home Phone
Work Phone
Secondary Phone:
Please enter a valid phone number.
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Client's Date of Birth:
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Month
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Day
Year
The state of CO requires that the primary caregiver's date of birht be recorded to allow us to dispense certain prescription medications.
Email
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Woodmoor will not sell, rent, nor share email addresses to third parties. We may use your email to provide you with reminders, news, and information
How did you hear about our hospital?
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Google
Facebook
Website
Yelp
Drive by
Referred by existing client
If referred by an existing client, please list their name here:
Patient Information
Name:
Species
Breed
DOB or Age
Color
Male or Female
Spayed or Neutered
Pet #1
Pet #2
Pet #3
Is your pet Microchipped?
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Yes
No
Unknown - Please scan him/ her
Any previous serious illness or surgeries?
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Is your pet allergic to any medications or vaccinations, that you are aware of?
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What does your pet eat? (Brand name & type)
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Example: Hills I/D Wet, Purina Pro Plan Salmon and Rice Dry, etc.
Is your pet currently taking any medications or supplements? (over the counter & prescribed)
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Including: Flea/ Tick and heartworm preventatives.
Is there anything else we should be aware of?
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Please provide a date of your CANINE pets most recent vaccinations along with proof uploaded below or emailed to info@woodmoorvet.com.
Date of last vaccination:
Rabies
DAP-P
Leptospirosis
H3N8 - H3N2
Bordetella
Rattlesnake
Please provide a date of your FELINE pets most recent vaccinations along with proof uploaded below or emailed to info@woodmoorvet.com.
Date of last vaccination:
Rabies
FVRCP
FEL-v
Upload your vaccinations here:
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Please provide the name and phone number of the veterinarian where these vaccinations were administered:
Name
Phone Number
Agreement:
I understand that every effort will be made to achieve a successful outcome and to provide for all possible safety in hospital care and handling. I hereby authorize the hospital to receive, prescribe for, treat or perform surgery upon the pet listed above. Furthermore, I agree to pay fees for services rendered at the time the pet is discharged from the hospital or the service is otherwise terminated. I agree to pay for the reasonable costs of collection, attorney fees and court costs in the event that collection efforts become necessary. I agree that the venue of this action will be in the county where the hospital is located. I understand that attended veterinary care is not provided overnight. I am at least 18 years of age and legally liable for the decisions I make.
Overnight Staff:
Woodmoor Veterinary Hospital & Pet Lodge is not a 24-hour hospital facility. We do not have staff on premises 24-hours a day.
Payment:
I assume responsibility for all charges incurred in the care of this/ these animal(s). I also understand that these charges will be paid at the time of service. Should my account become delinquent I assume responsibility for all collection fees in addition to the amount of my bill. The forms of payment accepted are; Visa, MasterCard, American Express, Cash, Check and Care Credit.
By checking this box and entering my name in the Electronic Signature field below, I acknowledge that I have read and agree with Woodmoor Veterinary Hospital and Pet Lodge's Terms of Use and Privacy Policy.
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I Agree
Today's Date:
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Month
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Day
Year
Date
Signature
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