New Client & Patient Information Sheet

 

 

NEW   C LIENT   &   P ATIENT   I NFORMATION   S HEET  

 

Thank   y ou   f or   g iving   u s   t he   o pportunity   t o   c are   f or   y our   p et.     W e   w ill   b e   h appy   t o   a nswer   a ny   q uestions   y ou  

have   a bout   y our   p et’s   h ealth.   T o   e nsure   t he   b est   c are   p ossible,   p lease   t ake   t he   t ime   t o   f ill   i n   t he   f orm  

completely.    

 

 

CLIENT   I NFORMATION  

Date________________  

First   N ame__________________________________________Last   N ame______________________________________________________  

Spouse’s   n ame________________________________________________________________________________________________________  

Address_____________________________________________City____________________________State____________Zip_____________  

Home   P hone(______)________________________________Work   P hone   ( ______)___________________________ext._____________  

Cell(______)_______________________Email   A ddress______________________________________________________________________  

Drivers   L icense   # ________________________________Employer__________________________________________________________  

 

 

PATIENT   I NFORMATION  

Pet’s   N ame__________________________Sex:   !     M ale       !       F emale           N eutered/Spayed?   !       Y es   !     N o  

Species:     !     D og     !     C at     !     O ther________________________________  

Pet’s   D ate   o f   B irth   ( Month/Day/Year)______/_______/_______Breed_______________________Color____________________  

Does   y our   p et   h ave   a ny   a llergies,   s pecial   m edications,   o r   h ealth   p roblems   w e   s hould   k now   a bout?   ! Yes   ! No  

If   y es,   p lease   e xplain___________________________________________________________________________________________________  

___________________________________________________________________________________________________________________________  

What   t ype   o f   f ood   d oes   y our   p et   e at?___________________________________________Treats_______________________________  

Where   w ere   t he   m ost   r ecent   v accinations   g iven?____________________________________________________________________  

Who   w as   y our   p revious   v eterinarian?_____________________________________________Phone   ( ______)____________________  

Is   y our   p et   ( dogs   &   c ats)   o n   h eartworm   p reventative?   !     Y es     !     N o           W hat   t ype?______________________________  

Is   y our   p et   ( dogs   &   c ats)   o n   f lea/tick   p reventative?   !     Y es     !     N o                       W hat   t ype?______________________________  

 

 

How   d id   y ou   b ecome   a ware   o f   o ur   h ospital?  

!     R eferred   b y   a   f riend.     W hom   m ay   w e   t hank?__________________________________________________________  

!     D rove   b y  

!     P revious   c lient         !     O ur   W ebsite             !     Y ellow   P ages  

I   h ereby   a uthorize   t he   v eterinarian   t o   e xamine,   p rescribe   f or,   a nd   t reat   t he   a bove   d escribed   p et(s)   a nd   t o   p rovide   v accines   a nd  

parasite   c ontrol   a s   n eeded.   I   a ssume   r esponsibility   f or   a ll   c harges   i ncurred   i n   t he   c are   o f   t his   a nimal.   I   a lso   u nderstand   t hat   A LL  

PROFESSIONAL   F EES   A RE   D UE   A T   T HE   T IME   S ERVICES   A RE   R ENDERED.  

 

Signed___________________________________________________________________________Date____________________________________