New Client Form
ADVERTISEMENT
1 Input ____ Client No. _________
NEW CLIENT FORM
Primary Owner Name_________________________________________________________________________
Co-Owner Name ____________________________________________________________________________
Additional Authorized Agents ___________________________________________________________________
Primary Street Address ___________________________________________________ Apt. #_______________
City ____________________________________ State _____________________ Zip _____________________
Primary Home Phone _____________ Primary Cell Phone _____________ Primary Work Phone ____________
Co-Owner Home ________________ Co-Owner Cell ________________ Co-Owner Work _________________
Additional Phone Numbers ____________________________________________________________________
Previous Veterinary Clinic Name ______________________________________ City ___________ State _____
Phone Number _________________________________ May we call to get a history? Yes ____
No ____
How did you FIRST hear about us?
Referred by friend or relative
Name ______________________________________________
Yellow Pages
Driving by, saw sign
Mailer
Humane Society/County Dog Control
Other ________________________________________________________________________
E-mail (If you would like reminders sent via e-mail) _________________________________________________
Pet’s Name _______________________
Female/Male | Spayed/Neutered? Y/N
Birth date/ Age ____________
(Circle One)
Dog/Cat/Other ______________ Breed/Predominant Breed _____________________ Color(s) _______________
(Circle One)
Pet Insurance Company _________________________ Phone Number _____________ Policy Number __________________
Microchip? Y/N Number _______________________ Brand _____________ Tattoo? Y/N __________________________
Current Medications ______________________________________ Prescription Diet ________________________________
Any chronic health problems?
___________________________________________________________________________
Pet’s Name _______________________
Female/Male | Spayed/Neutered? Y/N
Birth date/ Age ____________
(Circle One)
Dog/Cat/Other ______________ Breed/Predominant Breed _____________________ Color(s) _______________
(Circle One)
Pet Insurance Company _________________________ Phone Number _____________ Policy Number __________________
Microchip? Y/N Number _______________________ Brand _____________ Tattoo? Y/N __________________________
Current Medications ______________________________________ Prescription Diet ________________________________
Any chronic health problems?
___________________________________________________________________________
Pet’s Name _______________________
Female/Male | Spayed/Neutered? Y/N
Birth date/ Age ____________
(Circle One)
Dog/Cat/Other ______________ Breed/Predominant Breed _____________________ Color(s) _______________
(Circle One)
Pet Insurance Company _________________________ Phone Number _____________ Policy Number __________________
Microchip? Y/N Number _______________________ Brand _____________ Tattoo? Y/N __________________________
Current Medications ______________________________________ Prescription Diet ________________________________
Any chronic health problems?
___________________________________________________________________________
Pet’s Name _______________________
Female/Male | Spayed/Neutered? Y/N
Birth date/ Age ____________
(Circle One)
Dog/Cat/Other ______________ Breed/Predominant Breed _____________________ Color(s) _______________
(Circle One)
Pet Insurance Company _________________________ Phone Number _____________ Policy Number __________________
Microchip? Y/N Number _______________________ Brand _____________ Tattoo? Y/N __________________________
Current Medications ______________________________________ Prescription Diet ________________________________
Any chronic health problems?
___________________________________________________________________________
ALL FEES ARE DUE AT THE TIME SERVICES ARE RENDERED
Fees not paid in full are subject to a $5.00 per month handling fee plus 1.5% interest charge.
By signing below you agree to the following:
The Primary Owner and Co-Owner are responsible for all billing and medical decisions made for the above listed pets and any additional pets
added on the New Patient Form. Payment in full is due upon discharge and under certain circumstances, a deposit will be required prior to
services being performed. Signee(s) must be 18 years old or older. Photo ID is required.
Signature (Owner) ___________________________________________________ Date ___________________
Signature (Co-Owner) ________________________________________________ Date ___________________
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business