New Client - Companion Animal Hospital

Date*

Client Information*

Name*

Spouse

Address*

Contact Number*

Preferred Contact Method*

Email

Employment Info

Work Phone

How did you find out about our hospital?

If other is selected, please specify here:

Referral? Whom may we thank?

Method of payment:

Cash

Debit

Discover

AMEX

MC

Visa

Care Credit

CareCredit - offers interest-deferred payments or monthly payments provided you have been approved through a Care Credit application. (Provide the info to the fields below.)

Patient Name:

Patient DOB:

Approx. Age (fill in if you don't know date of birth):

Select which one applies:

Family Member

Companion

Child's Pet

Outdoor Pet

Type:

Canine (Dog)

Feline (Cat)

Avian (Bird)

Exotic

If Exotic is selected, please specify:

Breed:

Male or Female?

Pet Color:

Spayed/Neutered?

Yes

No

Pet Health History (Please Answer All Of The Following Questions): Have you had veterinary care before today?

Yes

No

Veterinary Name/Hospital:

Phone Number:

Has your pet had any vaccinations before today?

Yes

No

Was there any reaction to the vaccinations? Yes/No. If "yes," explain:

Do you give your pet a monthly heartworm prevention?

Yes

No

Is your pet on any medications? Yes/No. If "yes," list:

Any diagnosed medical illness? Yes/No. If "yes," list:

Previous surgeries?

Surgery

Dental

Problems?

Yes

No

If Yes, please explain:

Submit forms: (Please provide the vaccination records, etc.) No file chosen

New Client Information