New Client Information Form
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1New Client Information Form
Stetson Hills Animal Hospital
Welcome to Stetson Hills Animal Hospital. Our staff is dedicated to providing optimal patient care and will do its utmost to make your pet's stay
pleasant and beneficial. Please feel free to ask any questions concerning the treatment of your pet or other policies of the clinic. Our facility is
not staffed 24 hours a day and therefore is unable to provide supervised, overnight care. To help us serve you better, please provide us with
Date ______________________
the following information.
Name _____________________________________________
Spouse's Name ______________________________________________
Address ___________________________________________
City ______________________
State _______
Zip __________
Home Phone ____________________________
Cell Phone ___________________________
Work Phone _____________________
E- mail address _____________________________________
Drivers License # ________________________(for check cashing purposes)
Preferred way to be contacted for reminders (circle one)
mail
e-mail
How did you choose our practice?
Yellow Pages
Location
Other (please specify)______________________________
Personal Recommendation (whom may we thank?) _________________________________________
Patient Information
Pet #1
Pet #2
Pet #3
Name
Breed
Date of Birth
Color
Female
Male
Female
Male
Female
Male
Sex: (circle)
Spayed
Neutered
Spayed
Neutered
Spayed
Neutered
Last Heartworm Prevention
Previous
Name
Veterinarian
Information
Hospital
Phone
Our pet is:
Member of Family
Child's Pet
Backyard Pet
Any previous illnesses or surgeries? _____________________________________________________________________________________
Any allergies to vaccinations or medications? _______________________________________________________________________________
Is your pet on any special diets or medications? _____________________________________________________________________________
Payment is due when services are rendered. Finance charges will be assessed to overdue balances.
_____________________________________________________________________
Signature of Owner or Agent
Stetson Hills Animal Hospital
3780 W. Happy Valley Rd. Suite 126
Glendale AZ 85310
(623)889-7090
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