Fillable Client Information Form printable pdf download

Today’s date: _____/_____/_____

CLIENT INFORMATION FORM

Mrs. ___ Mr. ___ Ms. ___ Dr. ___

First name: ________________________________________

MI: ________ Last name: __________________________________

Address: _______________________________________________________________________________________________________

City: _____________________________________________

State: ______ ZIP: _________________________________________

Home phone: (____) ___________________ Work: (____) ___________________ Cell: (____) __________________Email: ______

How did you hear about us?

Yellow Pages ____ Newspaper ____ Television ____ Hospital sign ____ Radio ____

Personal recommendation ____ (Whom can we thank? ________________________________)

Other: ________________________________________________________________________________________________________

Method of payment today

Payment is required at the time of service. For your convenience, we accept Mastercard, Visa, American Express, cash, or

check (with a valid driver’s license).

Please check one: Cash ❑ Check ❑ Debit/Credit ❑

How much information do you want to be given about your pet’s health?

❑ I want a full explanation—anything and everything.

❑ I want a brief explanation—just the important stuff.

❑ I just want to know if there’s anything I need to do—keep it simple.

Consent

You will be asked to sign a health plan confirming authorization of treatment after a tentative diagnosis. The details of

treatment, the risks of treatment, and/or the risk of not treating will be explained to you.

Pet information

Name: _________________________________________________________ Age/Birthday: _____________________

Species (cat, dog, etc.) ______________________ Breed _________________________________________________

Color ________________________________ Weight _____________ Male ❑ Female ❑

Spayed/neutered? Yes ❑ No ❑

Does your pet have allergies? Yes ❑ No ❑

Has your pet ever had a reaction to vaccines or medications? Yes ❑ No ❑

If yes, what? ____________________________________________________________________________________________________

List any major surgeries your pet has had: _________________________________________________________________________

List any behavior problems we need to be aware of: ________________________________________________________________

List any foods and treats you give your pet: ________________________________________________________________________

Client Information Form