NEW CLIENT FORM

Date 

Owner's Name     Home Phone  

Address     City State     Zip

 Work Phone      Cell Phone

E-Mail

Spouse / Other Name     Spouse Cell Phone 

Spouse's Work Phone   Spouse Employer Name    

PROFESSIONAL FEES ARE DUE AT THE TIME SERVICES ARE RENDERED.

WE WILL GLADLY PREPARE A WRITTEN ESTIMATE IF YOU DESIRE.

PLEASE ASK RECEPTIONIST OR DOCTOR.

Driver's License No     OR    Social Security No   

How did you become aware of our clinic?

    Clinic Sign        Yellow Pages        Internet Search Engine       Was Client Here Before   

    Personal Recommendation     Whom may we thank?

TELL US ABOUT YOUR PET (Please Submit A New Form For EACH Pet)

Pet's Name         Dog    Cat    Other

IF CANINE:   Your Dog's Breed    Color   

IF FELINE:  Please choose one of the following:  Short Hair     Medium Hair     Long Hair

Your Pet's Age or D.O.B.         Male    Female    Spayed    Neutered

YOUR DOG'S VACCINATION HISTORY

Rabies    Date of last Rabies vaccination 

DHLP Parvo Corona      Date of last DHLP Parvo Corona vaccination 

Bordatella     Date of last Bordatella vaccination     

Fecal Stool Sample     Date of last Fecal Stool Sample    

Heartworm Test/Prevention     Date of last Heartworm Test 

YOUR CAT'S VACCINATION HISTORY

Rabies    Date of last Rabies vaccination 

DIST-Rhino Chlamydia    Date of last DIST-Rhino Chlamydia vaccination 

Leukemia Vaccine     Date of last Leukemia vaccination     

Leukemia Test/FIV Test    Date of last Leukemia Test/FIV Test 

Feline Fecal Stool Sample     Date of last Fecal Stool Sample    

Has your pet had any previous serious illnesses or surgeries?  If so, please explain below.

Is your pet allergic to any medication or vaccination?    No    Yes    If so, what?

Is your pet currently on any special food or medication?    No    Yes    If so, what?

       

To prevent the spread of infectious diseases, all hospitalized and boarded animals must be current on all vaccines and free from internal and external parasites.  By clicking on the SUBMIT button below, you authorize the doctor to provide vaccines and parasite control as needed.

By submitting this online form, I agree to be responsible for authorizing procedures and/or paying for services.