New Client Form Step 1 of 333%Owner Name*Co-Owner NameAddress* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email AddressHome NumberWork NumberCell Number*Co-Owner Work NumberCo-Owner Cell NumberName of Previous ClinicPrevious Clinic Phone NumberRecommended by Whom?PetSelect One:*CatDogPocket PetAvianExoticPet InformationNameBreedMicrochip#Date of BirthColorSexSpayed or NeuteredLast Given Date of Vaccinations (ex: 09/20/20)RabiesDistemper (DAP / DA2PP)LeptoLymeBordatella (KC)Heartworm/Lyme Screen Test Last Given Date of Vaccinations (ex: 09/20/20)RabiesDistemper (FVRCP)Leukemia (FLV) Does your pet have a history of vaccine reactions?*YesNoWhat were the reactions? (please list)*Additional PetsDo you have additional pets?*YesNoSecond PetSelect One:CatDogPocket PetAvianExoticPet InformationNameBreedMicrochip#Date of BirthColorSexSpayed or NeuteredLast Given Date of Vaccinations (ex: 09/20/20)RabiesDistemper (DAP / DA2PP)LeptoLymeBordatella (KC)Heartworm/Lyme Screen Test Last Given Date of Vaccinations (ex: 09/20/20)RabiesDistemper (FVRCP)Leukemia (FLV) Does your pet have a history of vaccine reactions?*YesNoWhat were the reactions? (please list)*Third PetSelect One:CatDogPocket PetAvianExoticPet InformationNameBreedMicrochip#Date of BirthColorSexSpayed or NeuteredLast Given Date of Vaccinations (ex: 09/20/20)RabiesDistemper (DAP / DA2PP)LeptoLymeBordatella (KC)Heartworm/Lyme Screen Test Last Given Date of Vaccinations (ex: 09/20/20)RabiesDistemper (FVRCP)Leukemia (FLV) Does your pet have a history of vaccine reactions?YesNoWhat were the reactions? (please list)*Fourth PetSelect One:CatDogPocket PetAvianExoticPet InformationNameBreedMicrochip#Date of BirthColorSexSpayed or NeuteredLast Given Date of Vaccinations (ex: 09/20/20)RabiesDistemper (DAP / DA2PP)LeptoLymeBordatella (KC)Heartworm/Lyme Screen Test Last Given Date of Vaccinations (ex: 09/20/20)RabiesDistemper (FVRCP)Leukemia (FLV) Does your pet have a history of vaccine reactions?YesNoWhat were the reactions? (please list)*Fifth PetSelect One:CatDogPocket PetAvianExoticPet InformationNameBreedMicrochip#Date of BirthColorSexSpayed or NeuteredLast Given Date of Vaccinations (ex: 09/20/20)RabiesDistemper (DAP / DA2PP)LeptoLymeBordatella (KC)Heartworm/Lyme Screen Test Last Given Date of Vaccinations (ex: 09/20/20)RabiesDistemper (FVRCP)Leukemia (FLV) Does your pet have a history of vaccine reactions?YesNoWhat were the reactions? (please list)*Any medical conditions we should be aware of?Does your pet have any allergies to medications? If so, please list them.What food does your pet(s) eat?*Is your pet on any medications? Please include name, dose, and instructions. (This includes heartworm & flea/tick preventative, and supplements)Please use the space below to give us any relevant information for your pet.Do we have your consent to post your pet(s) pictures on our social media platforms?*YesNoI hereby authorize the veterinarian to examine, prescribe for, or treat the above pet(s).*YesNoUpload Pet Records Drop files here or General Policies We require established care between the veterinarian, client, and pet before treating or prescribing medications. Your pet must be examined yearly for continuous establishment. We reserve the right to discontinue care at any point.Financial PoliciesWe accept all forms of card payment (Visa, Amex, Discover, Mastercard), cash, and checks.Payment is due at time of service. Unpaid balances will incur a monthly fee and statement.It is the client's responsibility to request an estimate.Clinic SafetyDogs must be leashed at all times.Cats must be in a carrier. One per carrier.The client is responsible for the pet's behavior. Please keep them away from other pets and let staff know if they require certain accommodations due to behavioral concerns.Signature*Date* Date Format: MM slash DD slash YYYY I understand by electronically signing this document that I acknowledge and accept the terms above.If you need to schedule an appointment - Click HereEmailThis field is for validation purposes and should be left unchanged.
