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NEW CLIENT INFORMATION FORM

Date:

Owner's Name:

Owner's Address:

Street 1:

Street 2:

City:

State:

Zip:

Home Phone Number:

Work Phone Number:

Cell Phone Number:

Employer:

Driver's License Number:

How did you become aware of us?

Pet's Name:

Pet's Breed:

Pet's Color:

Pet's Sex

Male

Female

Neutered or Spayed?:

Yes

Diet (Name Of Your Pet's Food):

Name Of Pet's Heartworm Preventative:

Name Of Pet's Flea Preventative:

Pet's Current Medications:

Canine Medical History:

Rabies Vaccination:

Yes

DA2PP (Distemper/Parvo) Vaccination:

Yes

Bordetella (Kennel Cough) Vaccination:

Yes

Rattlesnake Vaccination:

Yes

Heartworm Test:

Yes

Fecal Exam (test for worms):

Yes

Feline Medical History:

Rabies Vaccination:

Yes

FVRCP (Infectious Disease) Vaccination:

Yes

FELV (Feline Leukemia) Vaccination:

Yes

FIP (Feline Infectious Peritonitis) Vaccination:

Yes

FELV/FIV Test:

Yes

Fecal Exam (test for worms):

Yes

May we contact your previous veterinarian for a records transfer?

Yes

Not Applicable

Previous Clinic's Name:

Previous Clinic's Address:

Street 1:

Street 2:

City:

State:

Zip:

DUE TO STATE LAW, ALL DOGS & CATS MUST BE CURRENT ON RABIES VACCINATION. To help prevent the spread of infectious disease, hospitalization and boarded animals must be current on required vaccinations. Proof of vaccination must be presented at time of check-in or vaccinations will be administered.

I understand every effort will be made to achieve a successful outcome and to provide for all possible safety in hospital care and handling. I hereby authorize this hospital to receive, prescribe for, treat or perform surgery upon the pet listed on this form and additional pets I present. Furthermore, I agree to pay fees for services rendered at the time the pet is discharged from the hospital or as agreed prior to treatment. I understand that a reasonable service fee will be accessed for each not-sufficient fund check and/or certified letter that must be sent. I understand that veterinary service is provided during nighttime hours as necessary in the judgement of the veteriarian on call. Continuous presence of qualified personnel may or may not be provided. If I neglect to pick up my pet within one week of this discharge date and fail to notify this hospital within that time period, steps as described by law will be undertaken to consider my pet(s) abandoned.

By Clicking The "Submit" Button, I Certify That I Am In Agreement With All Terms & Policies Of This Practice.