New Client Form
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1NEW CLIENT FORM
Thank you for choosing Community Pet Hospital for your pet’s healthcare needs. We are committed to
providing the highest quality medicine and service available. It is our privilege to serve you and we will gladly
answer any questions you may have regarding your pet’s health or our hospitals.
Tell us about you:
Owner Name:
Spouse/Alternate Name:
Address:
Home Phone:
Cell Phone:
eMail Address:
Emergency Contact Name:
Phone:
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How did you hear about us?
Client Referral
Internet
Yellow Pages
Other:
If referred, who may we thank?
(Please include first and last name): ____________________________________
Tell us about your pet:
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Pet’s Name:
Dog
Cat
Other: _____________
Age/Date of Birth (approx.):
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Breed:
Sex:
Male
Female
Neutered
Spayed
Color/Markings:
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Has your pet been treated for any illness in the past year?
Yes
No
Please specify problem, medications and diagnosis if known:
Previous Veterinarian and where medical records could be obtained:
Please list names and types of any additional pets:
I hereby authorize the veterinarian to examine, prescribe for and treat the above pet(s). I assume responsibility
for all charges incurred in the care of my pet(s). I have read and understand the referral policy, appointment
cancelation policy and financial policy.
Signature of Owner/Responsible Party: ___________________________________ Date: _____________
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