Client Information printable pdf download

Date

Thank you for giving us the opportunity to care for your pets.

So that we may become better acquainted, please complete the following.

Account

CLIENT INFORMATION

Owner(s)

Home Phone

Mobile Phone

Employer(s)

Address

Email Addrs(s)

City/St/Zip

County

PATIENT INFORMATION

Pet #1:

Pet #2:

Pet #3:

Name

Breed/Color

Date of Birth/Age

Sex/spayed or neutered?

Any previous serious illnesses or surgeries

Any allergies to vaccinations or medications

Special diets or medications

Rabies vaccine

Distemper vaccine

Kennel cough vaccine

Lyme disease vaccine

Fecal (stool sample)

Feline leukemia vaccine

FIP vaccine

FVRCP vaccine

Heartworm test/prevention

Would you like to be present during treatment of your pet(s)? __Yes ___No

How did you become aware of our clinic? ___ Drove By ___ CitySearch Review ___ Website ___ Previous client

___ Personal Referral (Whom may we thank?) ____________________

___ Getting Settled Magazine ____The Fort Lee Traveller ___ValPak

PROFESSIONAL FEES ARE TO BE PAID AT THE TIME SERVICES ARE RENDERED. PLEASE CHECK YOUR

PREFERRED METHOD OF PAYMENT BELOW.

We will gladly prepare a written estimate if you desire. Please ask the receptionist or doctor.

Please indicate choice of payment: ___ Cash ___ Visa ___ MasterCard ___ Discover ___ Amex

___ Care Credit

**We do not accept checks. Please initial that you are aware of this here: __________**

I AM RESPONSIBLE AND AGREE TO PAY IN FULL THE TOTAL CHARGES FOR SERVICES RENDERED AT THE TIME

OF DISCHARGE AND ANY FEES INCURRED FOR COLLECTION OF SAID CHARGES. I UNDERSTAND THAT THE

FEES ARE BASED ON TREATMENT DEEMED NECESSARY AT THE TIME OF EXAM, TREATMENT OR ADMISSION

AND THAT THE ESTIMATE FEE MAY BE RAISED OR LOWERED BY THE ADMINISTRATION OF TREATMENT,

MEDICATION, SURGERY OR DIAGNOSTIC TEST.

Signature _____________________________________ Date _________________

___________________________________________________________________________________________________

Signature of person presenting this pet for treatment if other than owner ____________________________________

Name _____________________________________________

Relationship to Owner __________________

Full Address ______________________________________________Telephone __________________________

Client Information

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