Download New Client/New Patient Form - Northside Veterinary Clinic

NORTHSIDE VETERINARY CLINIC
CLIENT INFORMATION
Thank you for giving us the opportunity to care for your animal(s). Please
fill out the following form completely.
REFERRED BY _____________________________ OR ___YELLOW PAGES, OR
____DROVE BY, OR OTHER _______________________
OWNER’S NAME _______________________________ SPOUSE _______________________________
STREET ADDRESS ______________________________________________________________________
CITY _____________________________ STATE _________________ ZIP _________________________
HOME # (_____)______________________ CELL PHONE #(______)__________________________
E-MAIL ADDRESS _______________________________________________________________________
OWNER’S DRIVER’S LICENSE # ________________________________________________________
ISSUING STATE____________________ DATE OF EXPIRATION __________________________
EMPLOYER______________________________________________________________________________
EMPLOYER ADDRESS __________________________________________________________________
WORK # (______)____________________________ EXT. _____________________________________
Upon request, we will gladly prepare an estimate before any services are
performed.
DUE TO STATE LAW AND INSURANCE REQUIREMENTS, ALL DOGS AND
CATS MUST BE CURRENT ON RABIES VACCINATION. Vaccination can be
updated at the time of your appointment if it is not current.
I understand every effort will be made to achieve a successful outcome and to provide for
all possible safety in hospital care and handling. I hereby authorize this hospital to
receive, prescribe for, treat or perform surgery upon the pet(s) listed on the following
page(s). Furthermore, I agree to pay for fees for services rendered at the time the pet is
discharged from the hospital. I agree to pay for the costs of collection in the event that
collection efforts become necessary. I understand that a service fee of $30.00 will be
assessed for each non-sufficient fund check and/or certified letter that must be sent.
SIGNATURE __________________________________
DATE ______________________
NORTHSIDE VETERINARY CLINIC
PATIENT INFORMATION
PET NAME ____________________________ OWNER’S LAST NAME ________________________
PET’S DATE OF BIRTH _______________ K-9 __________ FELINE ________
BREED __________________________
MALE _______ FEMALE _________
SPAYED ___________
NEUTERED ___________
COLOR/MARKINGS _____________________________________________
IS YOUR PET MICROCHIPED? YES _____ NO _____ MICROCHIP # ____________________
PREVIOUS HOSPITAL/CLINIC __________________________________________________________
ADDRESS _______________________________________ STATE ______________ ZIP ____________
TELEPHONE # (_____)____________________
MAY WE CALL TO GET YOUR PET’S RECORDS?
YES _______
NO ________
IS YOUR PET CURRENT ON VACCINES?
YES _______
NO ________
DAILY FOOD DIET ___________________________ AMOUNT FED _____________________
DO YOU GIVE YOUR PET TREATS?
YES _______
NO _________
LIST ALL DAILY/WEEKLY MEDICATIONS AND THE DOSAGE FOR EACH:
________________________________________________________________________
________________________________________________________________________
IS YOUR PET ON HEARTWORM PREVENTATIVE? YES ______
NO ________
IF YES, WHAT KIND OF PREVENTATIVE AND WHEN WAS THE LAST TIME YOU
GAVE IT? _____________________________________________________________________
IS YOUR PET ON FLEA PREVENTATIVE? YES ______
NO ________
IF YES, WHAT KIND OF PREVENTATIVE AND WHEN WAS THE LAST TIME YOU
GAVE IT? _____________________________________________________________________
MEDICAL HISTORY-PRIOR ILLNESS OR SURGERY ___________________________________
__________________________________________________________________________________________