New Client Form printable pdf download

FLORIDA VETERINARY HOSPITAL

NEW CLIENT INFORMATION FORM

Dr. Mario Arteaga, D.V.M.

904 Avenida Central

The Villages, Fl. 32159

Office 352 750-2377

Owner Name: _____________________________ Home Phone: _______________________

Mailing Address: __________________________ Work Phone: _______________________

_________________________________________ Cell Phone: ________________________

County: __________________________________

Email Address: _______________________________________________________________

Driver’s License #: ____________________________

DOB: _______________________

Social Security #: _____________________________

Pet Name: _______________________________________ Dog or Cat: ___________________

Client Name ___________________________Pet Name __________________________

Pet Name: _______________________________________ Dog or Cat: ___________________

Pet Health Questionnaire

May we ask how you heard about our hospital? :

Thank you for coming in today to see us for your pet’s examination. Please take time to answer

the following questions regarding your pet.

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______________________________________________________________________________

1: What kind of food do you feed your pet? ___________________________________

2) How much do you feed? ________________________________________________

Payment is due when services are rendered. We accept personal checks, Visa, MasterCard,

3) Have you noticed any new lumps or bumps? ________________

American Express, Care Credit and ATM debit cards.

If so, where? _____________________________________________________________

Initials: _________________

4) Is your pet doing any of the following: Itching, scratching, shaking head, or chewing?

To prevent the spread of infectious diseases and parasites, hospitalized and boarded pets must be

on skin? ________________If so, describe _____________________________________

current on all vaccines and free of internal and external parasites. I authorize the doctor to

provide vaccines and parasite control as necessary for my pet.

5) Do you provide home dental care for your pet? If so what _______________________

Have you noticed bad breath? ____________________________________________

Print Owner Name: _________________________________________________________

Client Name ___________________________Pet Name __________________________

Owner Signature: __________________________________________________________

New Client Form