New Client Form

Name*

First Last

Email*

Phone*

Address*

Street Address Address Line 2 City State / Province / Region

Employer

Work Phone

Spouse/Partner/Other Pet Owner

First Last

Other Phone Number

In case of Emergency, who should we contact? (please include phone or email)*

Have you been in before? If yes, with which pet?*

Were you referred by someone?

Pet Information

Pet's Name*

Type of Animal*

Pet's Age/Birthday*

Breed*

Weight*

Color*

Is your pet fixed?*

At what age was your pet fixed?*

Where did you obtain your pet?*

At what age did you obtain this pet?*

For what purpose was the pet obtained?*

Diet information: Food, brand, wet or dry, and amount fed daily?*

Vaccine History/Dates? Please include all that apply: DHLP (Distemper-Dog) Parvovirus (Dog) FVRCP (Infectious Diseases-Cat) Feline Leukemia Test (Cat) Feline Leukemia Vaccine (Cat) Rabies (Cat/Dog) **

Please provide your pet's dental health history.*

Does your pet have any major prior illnesses? Surgery?*

Describe the reason for your pet’s visit:*

PAYMENT: We will gladly prepare a written estimate if you so desire (please ask our doctor or receptionist). ALL PROFESSIONAL FEES DUE AT THE TIME SERVICES ARE RENDERED. In cases of extensive medical or surgical procedures where full payment may be difficult at discharge, we accept major credit cards and care credit. There will be a service charge for any check returned unpaid. To prevent the spread of infectious diseases, all hospitalized patients must be current on all vaccines and free from internal and external parasites. The signature below authorizes this level of preventative care and the appropriate charges will be assessed in the discharge invoice*

I have read and understand.

Digital Signature*

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Welcome, new client!

Pet Information

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