Pet Guardian’s Name *

Spouse/Other

Mailing Address

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone *

Cell Phone *

Spouse Cell

Email *

Employer

Work Phone

May we send e-mail reminders and correspondence? *

Yes
No

May we call you at work: *

Yes
No

In an emergency: *

Yes
No

May we send text message reminders to your cell phone?

Yes
No

Spouse Employer

Spouse Work Phone

May we call your spouse at work

Yes
No

In an emergency:

Yes
No

What has been your past experience with veterinarians, if any? *

Please explain:

If you have been to another vet with your pet(s), which one was it and may we call for records?

What is your pet’s role in the family? *

If other, please specify *

Who is the primary care taker of the pet?

Who is responsible for healthcare decisions?

How did you hear about our practice?

Sign
Yellow Pages
Referral
Other

Who?

If other, please specify

Why did you choose our practice?

Please list all of your pets below:

Pet's Name *

Age / DOB *

Species *

Cat
Dog
Other

If other, please specify *

Gender *

Male
Female
Neutered Male
Spayed Female

Description

(Breed, Color, Long Hair/Short Hair)

Do you have a second pet? *

Yes
No

Pet's Name *

Age / DOB *

Species *

Cat
Dog
Other

If other, please specify *

Gender *

Male
Female
Neutered Male
Spayed Female

Description

(Breed, Color, Long Hair/Short Hair)

Do you have a third pet? *

Yes
No

Pet's Name *

Age / DOB *

Species *

Cat
Dog
Other

If other, please specify *

Gender *

Male
Female
Neutered Male
Spayed Female

Description

(Breed, Color, Long Hair/Short Hair)

Do you have a forth pet? *

Yes
No

Pet's Name *

Age / DOB *

Species *

Cat
Dog
Other

If other, please specify *

Gender *

Male
Female
Neutered Male
Spayed Female

Description

(Breed, Color, Long Hair/Short Hair)

Do you have a fifth pet? *

Yes
No

Pet's Name *

Age / DOB *

Species *

Cat
Dog
Other

If other, please specify *

Gender *

Male
Female
Neutered Male
Spayed Female

Description

(Breed, Color, Long Hair/Short Hair)

PAYMENT IS DUE AT THE TIME THAT SERVICES ARE RENDERED.

We accept Cash, Check, Visa, Mastercard, Discover, American Express, and/or Care Credit. We will gladly prepare a written Treatment Plan if you desire (please ask a receptionist or nurse). For services estimated to be over $75.00, we require a $50.00 deposit or 50% of the estimated total (whichever is greater) at the time the pet is dropped off. There will be a $30.00 service charge for any check returned for non-sufficient funds.

To prevent the spread of infectious diseases, all hospitalized and boarded patients must be current on all vaccines and free from internal and external parasites. The signature below authorizes this level of preventative care and the appropriate charges will be assessed in the discharge invoice.

Consent

If this box is checked, Pet Vet Hospital and Wellness Center has my permission to use any photo, video and/or radiograph of my pet for advertisement or learning purposes, example: posting on Facebook, Twitter, Instagram etc…

Date *

Pet Vet Hospital and Wellness Center New Client Form

NEW CLIENT FORM

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Location

Hours