"Pet Hospital New Client Form"

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NEW CLIENT FORM
Please print this form, fill it out, and bring it to the hospital at the time of your appointment. This will save you a
considerable amount of time when you arrive at the hospital for your appointment.
OWNER'S LAST NAME:__________________________ FIRST:__________________________
SPOUSE/OTHER:_______________________________________________________________
STREET:_______________________________________________ APT:___________________
CITY and STATE:________________________________________________________________
ZIP: ___________________________________________________________________________
HOME PHONE: (_____)________________________ E-MAIL:____________________________
OCCUPATION:__________________________________________________________________
EMPLOYER:____________________________________________________________________
WORK PHONE: (_________)________________________________________________________
How did you learn about our hospital?
____word of mouth
____sign
____yellow pages
____other_______________________________________________________________________
PET HEALTH HISTORY
PET'S NAME:___________________________________________________________________
SPECIES: ____Dog
____Cat
____Rabbit
____Guinea pig
____Hamster
____Ferret
____Other______________________
SEX: ____Male ____Neutered?
____Female
____Spayed?
Breed:____________________________________ Color:_______________________________
Birth Date: Month:_________Day:_________Year:_____________
VACCINATION HISTORY: (date, type, where shots were obtained)
________________________________________________________________________________
________________________________________________________________________________
Has your pet been to a veterinarian before?_____________________________________________
How was this experience for your pet?_________________________________________________
________________________________________________________________________________
Are there previous records for your pet that we should obtain?______________________________
If so, from what doctor or hospital?____________________________________________________
NEW CLIENT FORM
Please print this form, fill it out, and bring it to the hospital at the time of your appointment. This will save you a
considerable amount of time when you arrive at the hospital for your appointment.
OWNER'S LAST NAME:__________________________ FIRST:__________________________
SPOUSE/OTHER:_______________________________________________________________
STREET:_______________________________________________ APT:___________________
CITY and STATE:________________________________________________________________
ZIP: ___________________________________________________________________________
HOME PHONE: (_____)________________________ E-MAIL:____________________________
OCCUPATION:__________________________________________________________________
EMPLOYER:____________________________________________________________________
WORK PHONE: (_________)________________________________________________________
How did you learn about our hospital?
____word of mouth
____sign
____yellow pages
____other_______________________________________________________________________
PET HEALTH HISTORY
PET'S NAME:___________________________________________________________________
SPECIES: ____Dog
____Cat
____Rabbit
____Guinea pig
____Hamster
____Ferret
____Other______________________
SEX: ____Male ____Neutered?
____Female
____Spayed?
Breed:____________________________________ Color:_______________________________
Birth Date: Month:_________Day:_________Year:_____________
VACCINATION HISTORY: (date, type, where shots were obtained)
________________________________________________________________________________
________________________________________________________________________________
Has your pet been to a veterinarian before?_____________________________________________
How was this experience for your pet?_________________________________________________
________________________________________________________________________________
Are there previous records for your pet that we should obtain?______________________________
If so, from what doctor or hospital?____________________________________________________
Please check any symptoms/problems that you have noticed about your pet.
____Behavior problems
____Bleeding gums
____Breathing problems
____Coughing
____Diarrhea
____Gagging
____Head shaking
____Lack of appetite
____Limping
____Loss of balance
____Scooting
____Scratching
____Seems depressed
____Sneezing
____Thirst and/or urination increase
____Vomiting
____Weakness
____Other________________________________________________________________________
Pet's current medications:____________________________________________________________
_________________________________________________________________________________
What do you feed your pet?___________________________________________________________
Are there any other pets in your household?______________________________________________
__________________________________________________________________________________
____Do you travel with your pet?
____Do you board your pet?
Is your pet? ____indoors only
____outdoors only
____both
Do you have any particular health and/or behavior issues about which you would like advice?
________________________________________________________________________________
________________________________________________________________________________
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