New Client Form

Your First Name: *

Your Last Name: *

Date:

Address: *

City *

State/Province *

ZIP / Postal Code *

Email Address *

Home Phone: *

Work Phone:

Cell Phone:

Spouse / Co-Owner

Phone:

Email Address

Emergency Contact Name:

Phone:

How did you learn of our clinic?RecommendationwebsitePhone DirectorySignOther

If recommended, by whom?

Number of Dogs:

Number of Cats:

Other:

PET HEALTH HISTORY

Pet #1

Name of Pet:

Type of Pet:DogCatOther

Breed:

Color:

Birthdate:

Neutered or Spayed?Male - NeuteredMale - Not NeuteredFemale - SpayedFemale - Not Spayed

Vaccination History (date and type of last vaccinations)

Please check any symptoms or problems that you have with your pet:Behavior ProblemsBleeding GumsBreathing ProblemsCoughingDiarrheaEyes Bulging or BloodshootGaggingLack of AppetiteLimpingLoss of BalanceScootingScratchingSeems DepressedShaking HeadSneezingThirst and/or Urination IncreasedVomitingWeaknessOther

If other, please list:

Pet's current medications:

Describe your pet's diet:

Pet #2

Name of Pet:

Type of Pet:DogCatOther

Breed:

Color:

Birthdate:

Neutered or Spayed?Male - NeuteredMale - Not NeuteredFemale - SpayedFemale - Not Spayed

Vaccination History (date and type of last vaccinations)

If other, please list:

Pet's current medications:

Describe your pet's diet:

Pet #3

Name of Pet:

Type of Pet:DogCatOther

Breed:

Color:

Birthdate:

Neutered or Spayed?Male - NeuteredMale - Not NeuteredFemale - SpayedFemale - Not Spayed

Vaccination History (date and type of last vaccinations)

If other, please list:

Pet's current medications:

Describe your pet's diet:

Pet #4

Name of Pet:

Type of Pet:DogCatOther

Breed:

Color:

Birthdate:

Neutered or Spayed?Male - NeuteredMale - Not NeuteredFemale - SpayedFemale - Not Spayed

Vaccination History (date and type of last vaccinations)

If other, please list:

Pet's current medications:

Describe your pet's diet:

AUTHORIZATION

I hereby authorize the veterinarian to examine, prescribe for , or treat the above described pet. I assume responsibility for all charges incurred in the care of this animal. I also understand that these charges will be paid at the time of release and that a deposit may be required for surgical treatment.

Signature of Owner *

Date *

Method of Payment *CashCheckMC/VISADiscoverAmExOther

If other, please explain:

Please do not fill in this field.

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