New Patient Information Sheet
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1NEW PATIENT & CLIENT INFORMATION SHEET
Welcome to Brodhead Veterinary Medical Center. So we may provide you with exceptional service, please share
information about you and your pet(s).
Our mission is to provide our clients with the very best loving,
compassionate veterinary health and wellness care from before hello to beyond good-bye. We offer veterinary care
and lodging for your best friends.
PATIENT INFORMATION
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Pet’s name:___________________________
Sex:
Male
Female
Neutered or spayed?
Yes
No
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Species:
Dog
Cat
Bird
Ferret
Reptile
Rabbit
Other _____________________________________
Pet’s Date of Birth (Month/Day/Year)_____/_____/_____ Breed__________________________ Color_____________________
Reason for bringing pet in:__________________________________________________________________________________
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Does your pet have any allergies, special medications, or health problems we should know about?
Yes
No
If yes, what? _____________________________________________________________________________________________
What type of food does your pet eat?_____________________________________ Treats? ______________________________
Dates of last vaccinations
:
Dogs
: DA2PP (Distemper/Adenovirus/Parainfluenza/Parvo): ___________ Rabies:___________ Kennel cough:____________
Is your dog on heartworm preventives? □ Yes □ No
Heartworm test: ___________
:
Cats
FVRCP
):____________ Rabies:____________ Feline leukemia:_____________
(Feline Rhinotraceitis/Calicivirus/Panleukopenia
Where were the most recent vaccinations given?________________________________________________________________
Who is your previous veterinarian?_______________________________________________ Phone (____)________________
CLIENT INFORMATION
First name ____________________________________ Last name ________________________________________________
Spouse first name _______________________________ Spouse last name __________________________________________
Address___________________________________ City_________________________ State__________ Zip______________
Home phone (______)______________ Work phone (_____)_______________ Ext_______ Cell (_____)_________________
E-mail address ________________________________________ Employer _________________________________________
How did you become aware of our clinic?
□ Referred by friend Whom may we thank? _______________________________________________ City _______________
□ Referred by veterinarian Whom may we thank? ____________________________________________
□ Drove by
□ Previous client
□ Website,
□ Yellow pages □ Facebook
We appreciate payment when services are rendered. For your convenience, we accept cash, check,
MasterCard, Visa and Discover. I verify that all the information provided is accurate.
Signed_________________________________________________________________ Date________________________________
Folder: Client Communication, File: New Client Registration Form.doc
105
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