New Client Form 2025

New Client Form
Client Information - Please fill out completely
First & Last Name:
Significant Other's First & Last name:
[Approval granted until otherwise withdrawn in writing]
Primary Phone:
Please enter a valid phone number.Format: (000) 000-0000.
What type of phone number is this?
Secondary Phone:
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Client's Date of Birth:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearThe state of CO requires that the primary caregiver's date of birht be recorded to allow us to dispense certain prescription medications.
Email
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?
If referred by an existing client, please list their name here:

Patient Information

Rows	Name:	Species	Breed	DOB or Age	Color	Male or Female	Spayed or Neutered	MicrochippedY/N
Pet #1
Pet #2
Pet #3

Do you have pet insurance?
If yes, which company?
Any previous serious illness or surgeries?
Is your pet allergic to any medications or vaccinations, that you are aware of?
What does your pet eat? (Brand name & type)
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)
Including: Flea/ Tick and heartworm preventatives.
Is there anything else we should be aware of?

Please provide a date of your CANINE pets most recent vaccinations along with proof uploaded below or emailed to info@woodmoorvet.com.

Rows	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.

Rows	Date of last vaccination:
Rabies
FVRCP
FEL-v

Upload your vaccinations here:

Cancelof
Please provide the name and phone number of the veterinarian where these vaccinations were administered:

NamePhone 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.
Today's Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Signature
Should be Empty:

New Client Form

Agreement:

Overnight Staff:

Payment: