New Client Form Harris Pet Hospital printable pdf download

NEW CLIENT FORM

Please print this form, fill it out, and bring it to the hospital at the time of your appointment. This will save you a

considerable amount of time when you arrive at the hospital for your appointment.

OWNER'S LAST NAME:__________________________ FIRST:__________________________

SPOUSE/OTHER:_______________________________________________________________

STREET:_______________________________________________ APT:___________________

CITY and STATE:________________________________________________________________

ZIP: ___________________________________________________________________________

HOME PHONE: (_____)________________________ E-MAIL:____________________________

OCCUPATION:__________________________________________________________________

EMPLOYER:____________________________________________________________________

WORK PHONE: (_________)________________________________________________________

How did you learn about our hospital?

____word of mouth

____sign

____yellow pages

____other_______________________________________________________________________

PET HEALTH HISTORY

PET'S NAME:___________________________________________________________________

SPECIES: ____Dog

____Cat

____Rabbit

____Guinea pig

____Hamster

____Ferret

____Other______________________

SEX: ____Male ____Neutered?

____Female

____Spayed?

Breed:____________________________________ Color:_______________________________

Birth Date: Month:_________Day:_________Year:_____________

VACCINATION HISTORY: (date, type, where shots were obtained)

________________________________________________________________________________

Has your pet been to a veterinarian before?_____________________________________________

How was this experience for your pet?_________________________________________________

________________________________________________________________________________

Are there previous records for your pet that we should obtain?______________________________

If so, from what doctor or hospital?____________________________________________________

New Client Form Harris Pet Hospital