NEW CLIENT REGISTRATION INTAKE

NEW CLIENT REGISTRATION
Name*

First NameLast Name
Address*

Address

Street Address Line 2

CityState

Zip
Cell Phone*
Alternate Phone
Email*
example@example.com
How did you hear about Animal Care Center?*

Social MediaInternet SearchSign / Walk-inRecommendation or Referral
If recommended by whom
NEW PET HEALTH HISTORY
Name of pet*
Breed*
Color*
BirthdateAge*

MonthDayYear
Date
Pet Species*

DogCat
Sex*

MaleFemale
SpayedNeuteredIntact
When was the last time your pet went to the veterinarian for routine wellness care?*

Within the last 6 monthsWithin the last yearMore than a year ago
What is your pet's vaccination status?*

Current on all vaccinesNeeds vaccination updates
Do you have previous medical records to share about your pet?*

YesNo
Have you had your pet's records emailed to records@accfernley.com yet?*

YesNo
File Upload

Upload Your Pet's Medical Records Here
Cancelof
Date records were emailed or uploaded.*

MonthDayYear
Date
Who was your previous veterinary care provider*
Type NONE if none
Does your pet receive monthly heartworm, flea and tick prevention year round?*

YesNo
If yes, what products do you use?
Type NONE if not applicable
Does your pet have any pre-existing medical conditions?*

YesNo
If yes please list medical conditions
Type NONE if not applicable
Is your pet currently taking any medications?*

YesNo
If yes please list medications
Type NONE if not applicable
Did you recently acquire your pet?*

YesNo
If yes where did you get your pet
Type NONE if not applicable
Does your pet have any allergies or sensitivities we need to be aware of?*

YesNo
If yes please list allergies
Type NONE if not applicable
What concerns would you like to address with the doctor?*
Type NONE if none
AUTHORIZATION
I hereby authorize the veterinarian to examine, prescribe for, or treat the above-described pets. I assume responsibility for all charges incurred in the care of these animals. I also understand that these charges will be paid at the time of release and that a deposit may be required prior to performing the treatment.
Signature of Owner*

Clear
Date*

MonthDayYear
Date
Should be Empty:

NEW CLIENT REGISTRATION

NEW PET HEALTH HISTORY

AUTHORIZATION