CBV - New Client Form

Appointment Information

Fernwood Veterinary Clinic
Thank you for giving us the opportunity to care for your pet. Please help us better meet your pet's needs by taking a moment to share some important information we will need as we support your pet's needs today and in the future.

Please be aware that new clients are required to pay a deposit equal to the exam fee at the time of booking their first appointment. This fee is fully applied to the appointment, however – cancelling the appointment within 24 hours of its scheduled time will result in a forfeit of the deposit.
Do you already have an appointment booked with us?*

YesNo
If no, what day and time would like to request?

MonthDayYearHourMinutesAM/PM Option
Please note that your appointment is not booked until it has been confirmed by

At Home Vet Care
Owners Information
Full Name*

First NameLast Name
Primary Phone Number*

Area CodePhone Number
Alt. Phone Number

Area CodePhone Number
E-mail*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Spouse's Information
Spouse's Name

First NameLast Name
Spouse's Phone Number

Area CodePhone Number
Spouse's E-mail
May we send you reminders, notices, and information by email?
Preferred Pronouns
Pet Information
Please fill out all of the following information about your pet.
Pets Name*
Species*
Breed*
Color*
Birth Date

MonthDayYear
Brith Date
Birth Date*

MonthDayYear
Sex*

FemaleMale
Fixed*

YesNoUnsure
Last Vaccinations
Previous Clinic
Medical Issues
Pet Insurance*

YesNo
If yes, which company
Policy #
Microchip/Tattoo #
Have your pets traveled outside of the area?*

YesNo
If yes, where have they traveled?
Do you have any other pets?
Should be Empty:

Appointment Information

Owners Information

Spouse's Information

Pet Information