New Client Form

Co-Owner Name (first & last):

Co-Owner Phone Number:

What is the best phone number to reach you?

How did you hear about us?

Friend

Newspaper Ad

Website/Internet Search

Facebook

Sign

Other

If you were referred by a client, what is their name?

Pet's Name

Species

Breed

Color

Sex

Female Intact

Female Spayed

Male Intact

Male Neutered

Age / DOB

Where and where was your pet obtained?

Is your pet:

Indoor

Outdoor

What is your pet's current diet/food?

Go for daily walk?

yes

no

Visit the dog park?

yes

no

Swim?

yes

no

Go to the groomer?

yes

no

Board or go to Daycare?

yes

no

Please list your pet's previous vaccines:

Please list your pet's medical conditions (ex: arthritis, allergies)

Please list your pet's current medications:

Is your pet currently on Heartworm prevention?

yes

no

Is your pet currently on Flea and/or Tick prevention?

yes

no

I understand that my pet’s picture may be used on social media sites.

YES, you can use my pet's photo on social media.

NO, do not use my pet's photo on social media.

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 the 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. I agree to pay all costs, expenses, statement fees, handling fees, collection and attorney's fees as allowed by law, either expected or incurred due to non-payment.

I agree

I do not agree

We are only able to accept checks from established clients. Please let us know how you will be paying today:

Cash

Mastercard

Visa

Discover

Care Credit