New Client Form

Name

PrefixFirst NameLast Name

Address

Street Address

Street Address Line 2

CityState

Zip Code

Primary Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Secondary Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

I would like to receive appointment confirmation via text:

Email

Confirmation EmailPlease use the same email address listed here with our FunkstownVet App.

Providing us with your email address will allow you access to our FUNKSTOWNVET app, where you can view your account, your pet’s records, and participate in our Loyalty Rewards program. Your email address will be used solely by our office for communication regarding your pet’s care and, on occasion, to share information about events or special offers. We will never sell or share your email address with outside parties.

Employers Name

Employers Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Work Phone

Please enter a valid phone number.Format: (000) 000-0000.

Are you Elligible for any of the following discounts?

Is there a Co-owner or second authorized individual you would like added to the account?

Co-Owner Name

First NameLast Name

Co-Owner Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Co-Owner Employer Name

Co-Owner Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Emergency Contact

First NameLast Name

Emergency Contact Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

How did you hear about us?

Individual(s) we may thank for your referral?

Method of payment (check all that apply):

Pet's name

Pet's age/Date of birth

Type of pet

Other

Breed

Sex/Status (please check one):

Color(s) and/or any Distinguishing Markings:

Patient Records Request

Previous Veterinary Hopsital name and phone number.

Please upload any previous Veterinary, Adoption or Humane Society records to our team.

Has your pet had any of the following:

Pets current medications:

Please list any and all medication or supliments you pet is currently taking including: Heartworm prevention, Flea and tick prevention, vitamins, joint suppliments, over the counter medications, or chronic medications.

Is your pet Current on their Rabies Vaccine?

Rabies Vaccine Expiration Date (even if past due)

Is your pet microchipped?

Microchip number (if known):

If your pet is covered by insurance, please provide the company name and policy number:

We do not bill insurance directly; reimbursement is handled between you and your provider. The only exception is Trupanion, which offers same-day direct payments to our hospital.

We love sharing the happy faces of our patients! May we use your pet's photo on our Social media (Facebook/Instagram), website or other media?

Clients Acknowledgements

I certify that the information I have provided is true and complete to the best of my knowledge. I acknowledge that I MUST PROVIDE A VALID DRIVERS LICENSE or government-issued PHOTO ID at my first visit. I understand that I am financially responsible for all services rendered, and that payment in full is due at the time of service. I acknowledge that I have been informed of the hospital’s policies regarding, payment, and communication. If my account becomes delinquent, I agree to be responsible for all costs of collection, including collection agency fees, attorney’s fees, and court costs. I agree to abide by these policies as a client of Animal Health Clinic of Funkstown.

New Client Form

Pet Owner's information

Pet's Information