New Client Form

Owner Information

Owner Last Name:

First Name:

Spouses Name:

Street Address:

City:

State:

Zip:

Cell Phone #:

Home/Work Phone:

Email:

Social Security #:

Emergency Contact:

Phone #:

How were you referred to our clinic?

Family/Friends Internet Doctor Referal Phone Book Other

Please let us know if a client referred you so we can thank them!

Pet Information

Pet's Name:

Date of Birth/Pets Age:

Species:

Dog Cat Other

Please Identify Species:

Sex:

Male Female

Has your pet been spayed or neutered?

Yes No

Breed:

Color:

Is your pet current on vaccinations?

Yes No

Where was your pet last vaccinated?

What is the reason for todays visit?

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 above. Furthermore, I agree to pay fees for all services rendered. I agree to pay for the reasonable costs of collection, attorney fees, and court cost in the event that collection efforts become necessary. I agree that the venue of this action will be in the county where the hospital is located. I understand that veterinary service is provided during nighttime hours as necessary in the judgment of the Veterinarian in charge. Continuous presences of qualified personnel may not be provided.

Signature:

Clear

Date

Month Day Year

PLEASE UNDERSTAND THAT PAYMENT IS DUE WHEN SERVICES ARE RENDERED!