New Client Information

New Client Information
Client Information
Name *

First Name Last Name

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Primary Phone Number *

- Area Code Phone Number
Primary Phone Type *
Secondary Phone Number *

- Area Code Phone Number
Secondary Phone Type *
Date of Birth *

- Month - Day Year
We are required by the DEA to obtain our clients' date of birth and keep it in our records.
Gender *
E-mail *
Spouse/Significant Other

First Name Last Name
Referral Information

Please let us know how you found out about our facility.
How did you find our practice? *
If you selected Community Event, Pet Store, Friend, Other Internet, or Other please tell us which one (person, place, event)
If you are not planning on using CVVH as your primary veterinarian please list your primary veterinarian below. It is important for us to have this information so we can send records from your visit to your regular veterinarian if you are planning to continue care at your regular veterinarian. Having access to this information also allows our boarding staff to request records and proof of vaccination from your pet's regular veterinarian.
Do you have a primary veterinarian? *

Yes No
Practice Name
Veterinarian name
Patient Information
Pet Name *
Species *
If you selected Other, which species
Breed *
Color *
Approximate Date of Birth *

- Month - Day Year
Sex *
Current on Vaccines? *

Yes No
Pet Name
Species
If you selected Other, which species
Breed
Color
Approximate Date of Birth

- Month - Day Year
Sex
Current on Vaccines?

Yes No
Pet Name
Species
If you selected Other, which species
Breed
Color
Approximate Date of Birth

- Month - Day Year
Sex
Current on Vaccines?

Yes No
Authorization

I hereby authorize the veterinarian to examine, prescribe for, and/or treat the above described pet(s). As the owner or acting on behalf of the owner, I assume responsibility for all the charges incurred in the care of this animal. I understand that payment is due at the time of service. I also understand that a deposit will be required for surgical, diagnostic, and/or emergency treatment and that all charges will be paid in full at the time of release. All accounts left unpaid after 30 days will accrue an 18% APR as well as a $5.00 monthly statement fee. After 60 days all overdue accounts are sent to a collection agency and additional fees apply. Past due accounts are subject to the cost of collection and legal fees and in the event of litigation, I am responsible for all court costs and attorney fees. I also authorize Conejo Valley Veterinary Hospital and its representatives to utilize the pet’s name, any photos, and case information for marketing purposes, including social media, website, lecture materials, or other marketing-related publications.
I understand the above terms: *

I have read the authorization above and agree to the terms and conditions.
Signature *

Clear
Should be Empty:

New Client Information

Client Information

Referral Information

Patient Information

Authorization