New Client Information Form
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1Thank you for choosing our hospital to care for the health of your pet. We want you to feel comfortable in our
office and assured that your pet is well cared for. If you have any questions or concerns, please feel free to ask
one of our staff for assistance or discuss your concerns with the veterinarian. We are here to serve you!
Client Information:
Client Information:
Client Information:
Client Information:
Name(s):________________________________________ Mr.
Mrs.
Ms.
Dr.
first
last
Address: _________________________________________________________________________________
#
Street
Apt/Unit#
City
Postal Code
Home Phone:____________________________
Business Phone: _________________________________
Cell Phone:______________________________
E-mail:_________________________________________
Does any other person have authority to approve medical treatment? Yes
No
Please list contact information if appropriate:_____________________________________________________
Patient Information:
Patient Information:
Patient Information:
Patient Information:
Name:_____________________________ Dog
Cat
Other:_______________________ (please specify)
Breed:______________________
Colour:________________________
Male
Female
Birth date /Age: __________________ (mm/dd/yyyy)
Spayed/Neutered:
yes
no
Microchip: yes
no
Microchip number if known: ___________________________________
Pet Insurance: yes
no
Pet Insurance Provider/Number: _________________________________
Medical History:
Medical History:
Medical History:
Medical History:
Date of last vaccines: ____________________________ (mm/dd/yyyy)
Type of vaccines (if known): __________________________________________________________________
Previous Veterinarian: _______________________________________________________________________
Details of any previous medical problems: _______________________________________________________
__________________________________________________________________________________________
Other pets in household:_______________________________________________________________________
How did you find us?
How did you find
us?
How did you find
How did you find
us?
us?
Street View Signage
Yellow Pages
Website
Through a Friend________________________(please specify) Other_______________________(please specify)
Payment in full is due when services are rendered. For your convenience, payment may be made by Cash, Debit, Visa or Mastercard.
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Parent category: Medical