New Client Form

Thank you for choosing our hospital as your pet’s provider of veterinary services. Please complete this form as
fully as possible prior to your first appointment.

Owner Info

First Name

Last Name

Spouse/Co-owner

First Name

Last Name

Your Address

Address

City

State

Zip

Phone numbers

Primary phone number

HomeCellWork

Secondary phone number

HomeCellWork

Your employer

How did you hear about us?

Drive by/sign (if not, please leave empty. If yes, please write "Yes")

Internet search (if not, please leave empty. If yes, please name it)

Recommendation (If not, please leave empty. If yes, please name it)

Social media (If not, please leave empty. If yes, please name it)

Other (If not, please leave empty. If yes, please name it)

Pet information (please fill out this portion for each pet if you have multiple pets)

Pet name

Species (dog/cat)

Breed

Color

Sex

Spayed or Neutered?

Date of birth
Unknown date of birth
If exact date is unknown, enter approximate years old

Microchip
YesNo

Vaccination History – What vaccines were given and when (if known)

Previous veterinary practice (if any)

Previous veterinarian (if any)

Is your pet on any medication or supplement?
YesNo
If yes, please list the medication or supplement

What food does your pet eat?

Does your pet have allergies or drug reactions?
YesNo
If yes, please list the allergies and reactions

Are there any current or past medical conditions which we should be aware of?
YesNo
If yes, please comment on the condition(s) and indicate if they are current or past conditions

Do you already have an appointment scheduled?
YesNo

If yes, what is the date and time?

What is the reason for this visit?

Authorization: I hereby authorize the veterinarian to examine, prescribe for, or treat the above pet(s). I assume responsibility for all charges incurred in the case of the animal(s). I also understand that all professional fees are due at the time services are rendered. We accept cash, debit, credit cards and Care Credit.

Signature of responsible party:

Date:

The information on this form is strictly confidential and is to be used only by this practice to provide care and treatment for your pet.

Owner Info

Spouse/Co-owner

Your Address

Phone numbers

How did you hear about us?

Pet information (please fill out this portion for each pet if you have multiple pets)

Contact Info

Hospital Hours

About Us

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