New Client Form

New Client Form

Please fill out the following information to the best of your knowledge.
1553 S Novato Blvd Ste B
Novato CA 94947

Tel. (415) 892-0891
Thank you for entrusting us with the care of your pet! Please take a few moments to fill out this form so that we may learn a little more about you and your pet.
Client Name:*

First NameLast Name
Client Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Contact Number:*
Please enter a valid phone number.
Alternative Contact Number:
Please enter a valid phone number.
Email*
example@example.com
In the event of an emergency, please provide an alternate contact name and number:
Contact Name:

First NameLast Name
Relationship to Client:
Contact Phone Number:
Please enter a valid phone number.
Patient Information:
Patient Name:*
Species:*

CanineFeline
Breed + Color:*
Date of Birth *

MonthDayYear
Date
Age:*
Sex:*

MaleFemale
Spayed/Neutered:*

YesNo
In order to create an accurate medical record for your pet, please provide us with your pet’s prior veterinarian, rescue organization, or vaccine clinic so that we may obtain a vaccine and medical history. Any prior records, please provide it to us so that a copy can be made and the medical record can be updated:
Name of clinic, rescue organization or prior veterinarian:*
Is your pet currently on any flea or tick prevention?*

YesNo
Is your pet is currently on any medications, please list them below (mg/how often):*
Please list any concerns that you have:*
By signing this form you agree to the following:

In admitting my pet(s) for diagnostics, treatment, or surgery, I authorize the veterinarian of Center Veterinary Clinic, and their support staff, to administer such treatment and/or perform such diagnostic or surgical procedures as deemed necessary. It is understood that an estimate of charges will be provided to me. No guarantee or assurance can be made as to the results that may be obtained. Please keep in mind that estimates do not always reflect the final cost.
Further, I understand that a deposit of 50% may be required before services are performed and I assume full financial responsibility for all of the charges insured for the care/treatment of my pet(s). I realize that these charges may exceed a given estimate if complications arise. I understand that Center Veterinary Clinic will contact me prior to any treatment, if possible, should complications arise. Please note that payment is expected at the time of services rendered.
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty: