New Client Information Form

Mrs.Mr.Ms.Dr.

Your Name

Fellow Care Giver's Name (if applicable)

Street Address:

Street Address Line 2:

City:

State:

Postal / Zip Code:

Home Phone

Work Phone

Cell Phone

Your Email

How did you hear about us?

Hospital SignInternetNewspaperPersonal RecommendationOther

Other:

Whom can we thank?

Pet Information

Pet's Name

Age/Birthday

Species (cat, dog, etc.)

Breed

Color

Sex MaleFemale

Spayed/NeuteredYesNo

Does your pet have allergies? YesNo

Has your pet ever had a reaction to vaccines or medications? YesNo

List any major surgeries or health issues your pet has had:

Consent

You will be asked to sign a health plan confirming authorization of treatment after a tentative diagnosis. The details of treatment, the risks of treatment, and/or the risk of not treating will be explained to you.

Method of payment today

Payment is required at the time of service. For your convenience, we accept Mastercard, Visa, American Express, cash, check (with a valid driver’s license) or Care Credit.

I hereby grant the Animal Care Clinic the right to use the name and photograph or other likeness of myself and my pet in connection with its social media (ie: facebook) and promotional materials in any and all media including printed material, internet, and film.

Signature:

Date: