New Client Form
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1BOSTON VETERINARY ASSOCIATES, INC.
East Boston Animal Hospital
1007 Saratoga Street
East Boston, MA 02128
617-567-0101
New Client/Patient Registration
Date: _______________________
Owner’s Name(s): __________________________________________________
Date: ______________________________
Address: __________________________________
City: _______________________ State: _________
Zip: __________
Home Phone: ______________________ Work Phone: ______________________ Cell Phone: ______________________
Email Address: _____________________________________________________________
Emergency Contact(s): ______________________________________________ Phone: ____________________________
Pet’s Name: _________________________
Breed: ____________________
Canine
Feline
Other: ___________
Color: ______________ Birthdate: ______________
Male
Neutered
Female
Spayed
Is your pet up to date on their vaccines?
Yes
No
If yes where & when were they given? _____________________________________________________________________
Known allergies? __________________________________
Current medications? ______________________________
What is your pet’s reason for visiting us today? ____________________________________________________________
Please check any symptoms that you have noticed about your pet:
Vomiting
Lethargic
Sneezing
Scooting
Diarrhea
Increased Urine
Gagging
Smelly Ears
Loss of Appetite
Increased Thirst
Coughing
Eye Irritation
Depressed
Limping
Runny Eyes
Scratching
How did you hear of us?
By the phone book – Which one? ____________________________________________________
Referred by someone: - If so, who may we thank? ____ ____________________________________________________
Noticed the hospital when driving by.
Mail advertisement.
Television/Radio
Internet/Website
I hereby authorized the veterinarians & staff to examine, prescribe for, and/or treat the above-described pet.
I assume responsibility for all charges incurred in the care of this animal. I also understand that any and all
charges will be paid for at the time when services are rendered and that a deposit may be required for
hospitalization, treatment and/or surgery.
I understand that in order to protect my privacy, information regarding client and or patient information can
only be released to the owners named above, and a medical record release form will need to be completed
and signed by the above named owner(s).
EAST BOSTON ANIMAL HOSPITAL DOES NOT OFFER BILLING. ALL PAYMENTS ARE DUE IN FULL AT THE
TIME WHEN SERVICES ARE RENDERED. PLEASE INFORM EITHER A VETERINARIAN OR TECHNICIAN IF
YOU REQUIRE AN ESTIMATE BEFORE SERVICES ARE PERFORMED.
Signature of Owner: ___________________________________________________
Date: _____________________________
Please select your method of payment:
Cash
MasterCard
Visa
Discover
American Express
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