New Client Information Form

New Client Information Form
Primary Owner *

First Name Last Name
Secondary Owner /Contact

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Primary Phone Number *

Area Code Phone Number
Secondary Phone Number

Area Code Phone Number
Email
example@example.com
How did you hear about Eastern Animal Hospital
If you received a recommendation, who may we thank?
How would you like to receive reminders?
First Pet Information
Pets Name *
Species *
Breed *
Color *
Sex *
Spayed or Neutered *
Age/Birthday *
Microchipped *
Name of Pet Insurance Company
Previous Veterinary Clinic Name
Previous Veterinary Clinic Phone Number
Any known allergies
Diet Restrictions
Second Pet Information
Pets Name
Species
Breed
Color
Sex
Spayed or Neutered
Age/Birthday
Microchipped
Previous Veterinary Clinic Name
Previous Veterinary Clinic Phone Number
Any known allergies
Diet Restrictions
Payment Information
Please be aware that payment is due at the time of services. For your convenience, Eastern Animal Hospital accepts multiple types of payments. However, we do not offer billing and we do not accept personal checks. Please understand that payment is due at the time that services are rendered and a deposit will be required upon admission of your pet to the hospital for treatment. The balance will be due when your pet is discharged.
Your method of payment will be *
Photo and Information Release
Eastern Animal Hospital takes photographs for business purposes. I authorize and give full consent to Eastern Animal Hospital, it's representative, employees and assigns to take photographs of my pet and/or me and to copyright, use and publish the same in print and/or electronically (including Facebook and other social media forums). I further grant full permission to Eastern Animal Hospital, it's representatives, employees and assigns to use, or caused to be used, these photographs and/or either my name and/or my pet's name (if necessary) for any purpose (such as but not limited to advertising, marketing, publications, electronic distribution and the internet) without limitations or reservations whatsoever. This consent also serves to waive all rights of privacy or compensation which I may have in connection with the use of any photograph in which either my pet or I appear.
I authorize and give consent to the above *

Yes No
Date *

Month Day Year
Date
Should be Empty:

New Client Information Form

First Pet Information

Second Pet Information

Payment Information

Photo and Information Release