New Client Check-in Form

Client Name  ____________________________________

Address           ___________________________________

City, St   Zip    ___________________________________

Home Phone:   _____________________

Work Phone:    _____________________

Email Address:  ___________________________________

Would you like to be emailed a newsletter with info regarding clinic news, veterinary diseases, or other pertinent info??? (about once monthly…there will be no spam email or selling of information)

YES       NO

Pet Name:       ________________________________

Age                  _____________________

Sex (Circle one)      Male           Male Neutered           Female            Female Spayed

Breed               _____________________

Color               _____________________

Species (Circle one)     Dog       Cat      Other_________________

Drug Allergies_____________________

            Date of Last Vaccination:

                        Dogs                                               Cats

                        Rabies              __________              Rabies              ____________

                        Dhlp-p-c          __________                Fvrcp               ____________

                        Bordetella        __________               Felv                 ____________

                        Lymes              __________               FIP                   ____________

Payment is due in full at the time services are rendered.

How did you wish to pay for your visit today? 

       ____  Cash   

       ____  Credit Card  

       ____  Debit Card

** Unfortunately, because of a recent increase in hot checks, we are no longer able to accept personal checks from new clients.