Thank you for giving us the opportunity to care for your pet. To better serve you, please take a minute to complete the following: We never give away, sell, or distribute your information under any circumstances other than trying to reunite you with your lost pet. Please provide accurate and clear information—this may be needed to reunite you and your pet, especially if your pet is wearing our rabies tag.

Client Information

Owner's Name *

First

Last

Partner/Spouse

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone (Home) *

Cell Phone *

Spouse's Cell Phone

Which is the best phone number for us to reach you? *

Email *

Emergency Contact Name *

First

Last

Emergency Contact Phone Number *

Pet Information

Pet's Name *

Species (dog, cat, etc.) *

Breed *

Color *

Markings *

Age/Date of Birth *

Sex *

Male
Neutered Male
Female
Spayed Female

Does your pet have a microchip identification? *

Yes
No

What is the microchip number?

Date of Last Vaccines

Previous veterinarian where vaccines were given:

Please note any prior medical problems or conditions:

Current medications your pet regularly receives:

Which type of heartworm preventative does your pet take?

Which type of flea/tick preventative?

Do you have a second pet? *

Yes
No

Pet's Name *

Species (dog, cat, etc.) *

Breed *

Age/Date of Birth *

Sex *

Male
Neutered Male
Female
Spayed Female

Does your pet have a microchip identification? *

Yes
No

What is the microchip number?

Date of Last Vaccines

Previous veterinarian where vaccines were given:

Please note any prior medical problems or conditions:

Current medications your pet regularly receives:

Which type of heartworm preventative does your pet take?

Which type of flea/tick preventative?

Do you have a third pet? *

Yes
No

Pet's Name *

Species (dog, cat, etc.) *

Breed *

Age/Date of Birth *

Sex *

Male
Neutered Male
Female
Spayed Female

Does your pet have a microchip identification? *

Yes
No

What is the microchip number?

Date of Last Vaccines

Previous veterinarian where vaccines were given:

Please note any prior medical problems or conditions:

Current medications your pet regularly receives:

Which type of heartworm preventative does your pet take?

Which type of flea/tick preventative?

Do you have a fourth pet? *

Yes
No

Pet's Name *

Species (dog, cat, etc.) *

Breed *

Age/Date of Birth *

Sex *

Male
Neutered Male
Female
Spayed Female

Does your pet have a microchip identification? *

Yes
No

What is the microchip number?

Date of Last Vaccines

Previous veterinarian where vaccines were given:

Please note any prior medical problems or conditions:

Current medications your pet regularly receives:

Which type of heartworm preventative does your pet take?

Which type of flea/tick preventative?

Do you have a fifth pet? *

Yes
No

Pet's Name *

Species (dog, cat, etc.) *

Breed *

Age/Date of Birth *

Sex *

Male
Neutered Male
Female
Spayed Female

Does your pet have a microchip identification? *

Yes
No

What is the microchip number?

Date of Last Vaccines

Previous veterinarian where vaccines were given:

Please note any prior medical problems or conditions:

Current medications your pet regularly receives:

Which type of heartworm preventative does your pet take?

Which type of flea/tick preventative?

Does your pet associate with other animals(parks, grooming, boarding/training)? *

Yes
No

Is your pet exposed to ticks? *

Yes
No

Does your pet go to and/or swim in any lakes, ponds, or creeks? *

Yes
No

Reasons, questions, or concerns for this visit *

Do you require a Estimate with your initial visit? *

How did you hear about our hospital?

Personal Referral (please let us know who!)

I declare that I am the owner/agent of the pet(s) listed above and at least 18 years old. I hereby authorize release of prior medical records. I agree to pay for services as they are rendered (in order to keep costs to a minimum, we do not ever offer delayed payments). I agree to pay the total invoice before my pet will be discharged (the veterinarian may refuse to return possession of the pet(s) until all charges have been paid). In the event that payment is not forthcoming, I agree to pay any collection, legal, and court fees as well as interest at the standard rate. I authorize delinquent payments to be debited from my credit card on file (if applicable). I can be provided with an estimate for any surgeries or procedures, if requested, after the intitial examination. *

I have read and accept the financial policy.

Signature *

Clear Signature

Date *

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New Client Form

New Client Form

Client Information

Pet Information

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