New Client & New Patient History Form

Contact Information

Name

Birthday of primary owner on account

Address

City

State

Zip

Phone

Preferred method of contact (choose all that apply)

Phone Call Text Message Email

How did you hear about us?

Your Consent and Acknowledgement

ALL FEES ARE DUE UPON COMPLETION OF SERVICES

I hereby authorize the examination, prescription for, and/or treatment of my pet(s). I assume responsibility for all charges incurred in the care of this/these pet(s). I agree to pay all fees for all services rendered at the time the pet(s) is/are released from our care. Failure to pay on an active balance will result in a 15% service charge.

Acceptance

I acknowledge and agree to the terms and conditions of service.

Pet Information

Pet's Name

Pet Species

Sex

Spayed/ Neutered

Yes No Unsure

Breed

Color/Markings

Pet's Birthdate

Does your pet have a microchip

Yes No Unsure

How did you aquire your pet?

Previous Vet/Vet Clinic

Previous Vet/Vet Clinic contact number

Pet Medical History

Any other medical conditions you wish to explain?

Is your pet currently on any medications?

Yes No Unsure

What do you currently feed your pet? (Brand)

Food Variety

Wet Dry Mixed

How much do you feed?

How often do you feed?

Does your pet already have Flea/Tick Prevention?

Yes No

What kind of Flea/Tick prevention?

Does your pet already have heartworm Prevention?

Yes No

What kind of Heartworm prevention?

My Account

Forms

Resources

Partners and Rescues

Hill's To Home

Purina Pro Plan

My Account