New Client Form

Fairfield Veterinary Hospital

55 Ruane St

Fairfield, CT 06824

(203) 256-1955

info@fairfieldvh.com

**Please email records to above email**
Date*

MonthDayYear
Date
Date of Appointment*

MonthDayYear
Date
Owner Information
Owner Last Name
First Name
Street Address
City
Zip
Home Number

Area CodePhone Number
Cell Number

Area CodePhone Number
Work Phone:

Area CodePhone Number
Email
example@example.com
Spouse/Significant Other Name:
Spouse/Significant Cell:

Area CodePhone Number
Spouse/Significant Other Work:

Area CodePhone Number
Spouse/Significant Other Email:
example@example.com
Best Contact Number

Area CodePhone Number
Best Email:
example@example.com
How were you referred to our clinic?

Family/FriendsInternetDoctor ReferalPhone BookOther
Please let us know if a client referred you so we can thank them!
Pet Information
Pet's Name:
Species:

DogCatOther
Breed:
Color:
Date of Birth/Pets Age:
Sex:

MaleFemale
Has your pet been spayed or neutered?

YesNo
Microchip Number
How long have you owned your pet?
Where did you acquire your pet?
Food or drug allergies
Current Medications
Medical History/Prior Illness/Surgery:
I give permission for photos and videos of my pet to be used in all forms of social media.

YesNo
I hereby authorize the veterinarian to examine, prescribed for, or treat the above described animal. I also understand that these charges will be paid for at the time services are rendered.
Signature:

Clear
Date

MonthDayYear
Should be Empty:

Fairfield Veterinary Hospital