Pine Bluff Animal Hospital New Client Form

New Client Form
Owner Information
Name*

First NameLast Name
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
County
E-mail*
example@example.com
Home Phone
Format: (000) 000-0000.
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Spouse/Co-Owner Name

First NameLast Name
Spouse/Co-Owner Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Best Number To Call

HomeCell
Payment Preference

CashCheckCreditCareCredit
How Did You Hear About Us?

RadioSignFacebook/Instagram/TiktokYelpInternetNewspaperDwight Veterinary ClinicLakewood Animal HospitalSkinner Animal ClinicFriendOther HospitalEmployeeOther
If friend, what is their full name?
Which other hospital?
If an employee, what is their full name?
Pet #1 Information
Pet Name
Species

DogCatOther
Pet's Date of Birth Or Approximate Age
Breed
Color & Markings
Sex

MaleMale NeuteredFemaleFemale Spayed
Pet Insurance

YesNo
Microchip

NoYes
If yes, what is the #?
Significant Medical History or Allergens?
Current Medications?
If previously vaccinated or tested, where? Phone number?
Owner: please call to have previous hospital or medical facilities EMAIL ALL RECORDS to PineBluffVet@gmail.com NOW.
Has your dog been vaccinated or tested for:
Has your dog been vaccinated or tested for Rabies (1 yr or 3 yr)?

YesNo
If your dog has been vaccinated or tested for Rabies, what date were they vaccinated or tested on?
Has your dog been vaccinated or tested for Distemper (DA2PP)?

YesNo
If your dog has been vaccinated or tested for Distemper (DA2PP), what date were they vaccinated or tested on?
Has your dog been vaccinated or tested for Influenza (CIV)?

YesNo
If your dog has been vaccinated or tested for Influenza (CIV), what date were they vaccinated or tested on?
Has your dog been vaccinated or tested for Heartworm Test?

YesNo
If your dog has been vaccinated or tested for Heartworm, what date were they vaccinated or tested on?
Has your dog been vaccinated or tested for Intestinal Parasite Exam?

YesNo
If your dog has been vaccinated or tested for Intestinal Parasite Exam, what date were they vaccinated or tested on?
Has your dog been vaccinated or tested for anything else?
Has your cat been vaccinated or tested for:
Has your cat been vaccinated or tested for Rabies (1 yr or 3 yr)?

YesNo
If your cat has been vaccinated or tested for Rabies, what date were they vaccinated or tested on?
Has your cat been vaccinated or tested for Distemper (FVRCP)?

YesNo
If your cat has been vaccinated or tested for Distemper (FVRCP), what date were they vaccinated or tested on?
Has your cat been vaccinated or tested for Feline Leukemia?

YesNo
If your cat has been vaccinated or tested for Feline Leukemia, what date were they vaccinated or tested on?
Has your cat been vaccinated or tested for FeLV/FIV Test?

YesNo
If your cat has been vaccinated or tested for FeLV/FIV Test, what date were they vaccinated or tested on?
Has your cat been vaccinated or tested for Intestinal Parasite Exam?

YesNo
If your cat has been vaccinated or tested for Intestinal Parasite Exam, what date were they vaccinated or tested on?
Has your cat been vaccinated or tested for anything else?
Do you have any additional pets to add?

YesNo
Is it a cat or a dog?

CatDog
Pet #2 Information
Pet Name
Species

DogCatOther
Pet's Date of Birth Or Approximate Age
Breed
Color & Markings
Sex

MaleMale NeuteredFemaleFemale Spayed
Pet Insurance

YesNo
Microchip

NoYes
If yes, what is the #?
Significant Medical History or Allergens?
Current Medications?
If previously vaccinated or tested, where? Phone number?
Owner: please call to have previous hospital or medical facilities EMAIL ALL RECORDS to PineBluffVet@gmail.com NOW.
Has your dog been vaccinated or tested for:
Has your dog been vaccinated or tested for Rabies (1 yr or 3 yr)?

YesNo
If your dog has been vaccinated or tested for Rabies, what date were they vaccinated or tested on?
Has your dog been vaccinated or tested for Distemper (DA2PP)?

YesNo
If your dog has been vaccinated or tested for Distemper (DA2PP), what date were they vaccinated or tested on?
Has your dog been vaccinated or tested for Influenza (CIV)?

YesNo
If your dog has been vaccinated or tested for Influenza (CIV), what date were they vaccinated or tested on?
Has your dog been vaccinated or tested for Heartworm Test?

YesNo
If your dog has been vaccinated or tested for Heartworm, what date were they vaccinated or tested on?
Has your dog been vaccinated or tested for Intestinal Parasite Exam?

YesNo
If your dog has been vaccinated or tested for Intestinal Parasite Exam, what date were they vaccinated or tested on?
Has your dog been vaccinated or tested for anything else?
Has your cat been vaccinated or tested for:
Has your cat been vaccinated or tested for Rabies (1 yr or 3 yr)?

YesNo
If your cat has been vaccinated or tested for Rabies, what date were they vaccinated or tested on?
Has your cat been vaccinated or tested for Distemper (FVRCP)?

YesNo
If your cat has been vaccinated or tested for Distemper (FVRCP), what date were they vaccinated or tested on?
Has your cat been vaccinated or tested for Feline Leukemia?

YesNo
If your cat has been vaccinated or tested for Feline Leukemia, what date were they vaccinated or tested on?
Has your cat been vaccinated or tested for FeLV/FIV Test?

YesNo
If your cat has been vaccinated or tested for FeLV/FIV Test, what date were they vaccinated or tested on?
Has your cat been vaccinated or tested for Intestinal Parasite Exam?

YesNo
If your cat has been vaccinated or tested for Intestinal Parasite Exam, what date were they vaccinated or tested on?
Has your cat been vaccinated or tested for anything else?
Treatment Authorization Policy: I hereby authorize the veterinarian to examine, prescribe for, or treat the above described pet(s). I assume responsibility for all chargesaccrued in the care of this animal presented by me or my agents at Pine Bluff Animal Hospital. I also understand that the charges will bepaid in full at the time of services rendered or at release and that a deposit may be required for surgical treatment or hospitalization. Iunderstand that I am responsible for a returned check fee of $25. I agree to pay for the reasonable costs of collection, attorney fees, andcourt costs if collection efforts become necessary. I HAVE READ AND UNDERSTAND THE ABOVE "Treatment Authorization Policy". I AFFIRM THAT I AM AT LEAST 18 YEARS OF AGE, OR, IF IAM UNDER 18 YEARS OF AGE, I HAVE OBTAINED THE REQUIRED CONSENT OF MY PARENT/GUARDIAN AS EVIDENCED BY THEIRSIGNATURE BELOW. I ACCEPT:*
No Show Policy: I understand and acknowledge that it is the policy of the practice to monitor and manage appointment no-shows and late cancellations. PineBluff Animal Hospital's goal is to provide excellent care to each patient in a timely manner. If it is necessary to cancel an appointment, clientsare required to call, text or email at least 24 hours before their appointment time. Notification allows the practice to better utilizeappointments for other patients in need of prompt medical care. Appointments must be cancelled at least 24 hours prior to the scheduled appointment time. In the event a client and/or patient "no-show"for an appointment three times in the same year, Pine Bluff Animal Hospital reserves the right to request a non-refundable deposit to secureany future appointments. I HAVE READ AND UNDERSTAND THE ABOVE "No Show Policy". I AFFIRM THAT I AM AT LEAST 18 YEARS OF AGE, OR, IF I AM UNDER 18YEARS OF AGE, I HAVE OBTAINED THE REQUIRED CONSENT OF MY PARENT/GUARDIAN AS EVIDENCED BY THEIR SIGNATURE BELOW. IACCEPT:*
Digital Media Relase: I hereby grant the Pine Bluff Animal Hospital permission to use my testimonial or likeness in a photograph, video, or other digital media("Photo") in any and all of its publications, including web-based publications, without payment or other consideration, for purposes ofadvertising the hospital staff or services. I understand and agree that all Photos will become the property of the Pine Bluff Animal Hospitaland will not be returned. I hereby irrevocably authorize the Pine Bluff Animal Hospital to edit, alter, copy, exhibit, publish, or distribute anytestimonial and Photo for any lawful purpose. In addition, I waive any right to inspect or approve the finished product wherein my testimonialor likeness appears. Additionally, I waive any right to royalties or other compensation arising or related to the use of the testimonial orPhoto. I hereby hold harmless, release, and forever discharge the Pine Bluff Animal Hospital from all claims, demands, and causes of actionwhich I, my heirs, representatives, executors, administrators, or any other persons acting on my behalf or on behalf of my estate have ormay have by reason of this authorization. I HAVE READ AND UNDERSTAND THE ABOVE "Digital Media Release". I AFFIRM THAT I AM AT LEAST 18 YEARS OF AGE, OR, IF I AMUNDER 18 YEARS OF AGE, I HAVE OBTAINED THE REQUIRED CONSENT OF MY PARENT/GUARDIAN AS EVIDENCED BY THEIR SIGNATUREBELOW. I ACCEPT:
Today's Date

MonthDayYear
Date
Please verify that you are human*
Should be Empty:

New Client Form

Owner Information

Pet #1 Information

Has your dog been vaccinated or tested for:

Has your cat been vaccinated or tested for:

Pet #2 Information

Has your dog been vaccinated or tested for:

Has your cat been vaccinated or tested for: