Client Information Form
Thank you for allowing us to care for your pet. Please help us to better meet your needs by taking a moment to complete this information sheet.
Client Information
Today's Date
*
-
Month
-
Day
Year
Date
Owner's Name
*
First Name
Last Name
Spose/Co-Owner
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone
Please enter a valid phone number.
Cell Phone
*
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Email
*
example@example.com
In care of an EMERGENCY, please call
*
Emergency Contact Phone #
*
How did you hear about us?
*
Google
Facebook
Hospital Sign
Other Internet
Existing Client
Current Employee
Other Hospital/Doctor
Other
If existing client/current employee, other hospital/doctor, who can we thank?
*
Pet's Information
Pet Name
*
Species
*
Dog
Cat
Other
Breed
*
Color/Description
*
Age (Years)
*
Date of Birth (if known)
Sex
*
Male
Female
Altered or Spayed
*
Yes
No
Diet (Brand of Food)
*
Prior Illness. Please provide details.
Prior Surgeries. Please provide details.
Have you sent us your pet's medical history yet?
*
Yes
No
Please email a copy of your pet's records to poundridgevet@gmail.com or by fax to 917-764-4202. Alternatively, please provide us with the name of the hospital we can contact to get it.
*
Do you have another pet with you today?
*
No
Yes
Pet's Information - Pet #2
Pet's Name
*
Species
*
Dog
Cat
Other
Breed
*
Color/Description
*
Age (Years)
*
Date of Birth (If Known)
Sex
*
Male
Female
Altered or Spayed
*
Yes
No
Diet (Brand of Food)
*
Prior Illness. Please provide details.
Prior Surgeries. Please provide details.
Have you sent us your pet's medical history yet?
*
Yes
No
Please email a copy of your pet's records to poundridgevet@gmail.com or by fax to 917-764-4202. Alternatively, please provide us with the name of the hospital we can contact to get it.
*
Do you have another pet with you today?
*
No
Yes
Pet's Information - Pet #3
Pet's Name
*
Species
*
Dog
Cat
Other
Breed
*
Color/Description
*
Age (Years)
*
Date of Birth (If Known)
Sex
*
Male
Female
Altered or Spayed
*
Yes
No
Diet (Brand of Food)
*
Prior Illness. Please provide details.
Prior Surgeries. Please provide details.
Have you sent us your pet's medical history yet?
*
Yes
No
Please email a copy of your pet's records to poundridgevet@gmail.com or by fax to 917-764-4202. Alternatively, please provide us with the name of the hospital we can contact to get it.
*
Payment:
We accept cash, checks, all major credit cards, and CareCredit for your convenience. We are in compliance with the "Red Flags" rule passed by the FTC to ensure your identity and privacy are secure.
If you would like to leave your credit card on file as a convenience for future use, please initial here and inform the receptionist.
*
I understand that I may receive a written fee estimate if I request one and that a final fee will be based on actual services rendered. Payment is due as services are rendered. For hospitalized cases, a deposit is required in advance. The balance is due upon discharge from the hospital. In the event payment is not made at the time of service, it is our policy to apply a service charge to accounts with a balance over 30 days old. All returned checks will incur a charge of $35.00. In the event the account is referred for collection, balances owed will be subject to additional annual interest charges of 16%.
*
Today's Date
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: