New Client Form
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3Orland Veterinary Hospital
NEW CLIENT FORM
Thank you for giving us the opportunity to care for your pet(s).
So that we may become better acquainted, please complete the following:
CLIENT INFORMATION
Date ________________________
Name _____________________________________ Your DOB_______________ Spouse’s Name ____________
Address _________________________________ City _____________________ State ______ Zip
Phone _________________ Work Phone _________________ Cell Phone
Place Of Employment ________________________________ Best Time To Reach You
E-Mail Address
How did you become aware of our clinic?
€ Drove by
€ Yellow Pages
€ Previous Client
€ Other
€ Personal Recommendation (Whom may we thank?)
PET # 1
PET # 2
PET # 3
NAME
BREED
DATE OF BIRTH
COLOR
SEX; SPAYED OR NEUTERED?
LENGTH OF TIME OWNED
YOUR DOG’S VACCINATION HISTORY:
RABIES
DHPP-C/DHLPP (DISTEMPER/PARVO)
BORDETELLA (KENNEL COUGH)
OTHER: RATTLESNAKE, LYME, LEPTO
FECAL (STOOL SAMPLE)
HEARTWORM TEST/PREVENTION?
YOUR CAT’S VACCINATION HISTORY:
RABIES
FVRCP/LK (DISTEMPER/LEUK/RESP.)
OTHER: FIP, FIV, ETC.
FELV/FIV TEST
FECAL (STOOL SAMPLE)
Any previous serious illnesses or surgeries?
Any prior dentistry done? ____________________________________________________________________________
Any allergies to vaccinations or medications?
Is your pet on any special diets or medications?
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