NEW CLIENT FORM Thank you for giving us the opportunity to care for your pet(s). So that we may become better acquainted, please complete the following: Date ________________________ CLIENT INFORMATION Mrs. _____ Mr. _____ Ms. _____ Dr. _____ Name _____________________________________ Spouse’s Name Mailing Address City State Zip Physical Address City State Zip Home Phone _______________________________ Mobile Phone Spouse’s Phone _____________________________ E-Mail Address Place Of Employment ____________________________________ Driver’s License # __________________ How did you hear about us? Personal Recommendation/Friend (Whom may we thank?) Drove by Website/Internet Radio Yellow Pages Other ____________________________________ PET # 1 PATIENT INFORMATION PET # 2 PET # 3 NAME SPECIES (Dog, cat, etc.) BREED COLOR SEX: Girl, Spayed Girl, Boy, Neutered Boy? DATE OF BIRTH/AGE What do you feed your pet? If you offer treats, what do you use? Our pet(s) is/are: ❑ Member of our family ❑ Child’s pet ❑ Backyard pet Any previous serious illnesses or surgeries? Any allergies to vaccinations or medications? Is your pet on any medications? What else we should know? May we have permission to use photos of your pet(s) on our website, Facebook page and other social media outlets? Initial One: Yes ______ No ______ COMMUNICATION PREFERENCES How much information do you want to be given about your pet’s health? ❑ I want a full explanation—anything and everything. ❑ I want a brief explanation—just the important stuff. ❑ I just want to know what I need to do—keep it simple. CONSENT: You will be asked to sign a health care plan giving authorization of treatment after a tentative diagnosis. The details of treatment, the risks of treatment, and/or the risk of not treating will be explained to you. All fees are due at the time of service. Acceptable methods of payment include cash, debit cards and credit cards (Visa, Mastercard and Discover).