New Client Form
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1The Village Veterinarian
340 East 11th Street, New York, NY 10003
Phone: 212.979.9870 Fax: 212.979.6682
New Client Form
Thank you for giving us the opportunity to care for your pet. We’ll be happy to answer any questions you
have about your pet’s health. To insure the best care possible, please fill in this form completely.
Date ___________________
Pet Owner’s Name (first, last) ___________________________________________________________
Driver’s License # ____________________________________________________________________
Address ______________________________________________________ ZIP code ______________
Phone: Home _____________________ Cell ____________________ Work ______________________
Email
Spouse/Pet’s Co-Owner Name (first, last) __________________________________________________
Phone: Home _____________________ Cell ____________________ Work ______________________
Email
Feline
Canine
Pet Name ________________________________________ Species:
Breed ___________________________________________ Color _____________________________
Male
Female
Neutered
Spayed
Date of Birth _________________________ Sex:
I hereby authorize the veterinarian to examine, prescribe for, or treat the above-described pet. I assume
responsibility for all charges incurred in the care of this animal. I also understand that these charges will
be paid at the time of release and that a deposit may be required for surgical treatment.
Signature of Owner _____________________________________________ Date _________________
How did you hear about us? ____________________________________________________________
___________________________________________________________________________________
Recommendation? (who may we thank?) __________________________________________________
We gladly accept the following credit cards for your convenience: Visa, Master Card, Amex & Discover.
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