"New Client Form - Cottage Veterinary Care" - Pacific Grove

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COTTAGE VETERINARY CARE- NEW CLIENT FORM
Client Information
Name (First, MI, Last) ______________________________________________________________
Address_________________________________________________________________________
City______________________________________________Zip____________________________
Home Phone (____) ________________________ Cell Phone (____)________________________
Work Phone (____) ________________________ Employer _______________________________
Spouse___________________________________ Cell Phone (____)________________________
Emergency Contact Name _______________________ Phone (____) ______________________
Driver’s License #_______________________ E-mail____________________________________
How did you learn about Cottage Veterinary Care?
_______________________________________
Previous Veterinarian _____________________________Phone (____) ______________________
Primary reason for visit _____________________________________________________________
Pet Information
Pet’s Name _______________________________ Dog___ Cat___(indoor__ outdoor__)
Other___
Sex M___ F ___ Birthdate ______________ Age _____ Breed ___________________________
Color __________________________
Neutered/Spayed?
Yes ___ What age? ______ No ___
Pet Insurance? Yes ____ Company ____________________________________________ No ___
COTTAGE VETERINARY CARE- NEW CLIENT FORM
Client Information
Name (First, MI, Last) ______________________________________________________________
Address_________________________________________________________________________
City______________________________________________Zip____________________________
Home Phone (____) ________________________ Cell Phone (____)________________________
Work Phone (____) ________________________ Employer _______________________________
Spouse___________________________________ Cell Phone (____)________________________
Emergency Contact Name _______________________ Phone (____) ______________________
Driver’s License #_______________________ E-mail____________________________________
How did you learn about Cottage Veterinary Care?
_______________________________________
Previous Veterinarian _____________________________Phone (____) ______________________
Primary reason for visit _____________________________________________________________
Pet Information
Pet’s Name _______________________________ Dog___ Cat___(indoor__ outdoor__)
Other___
Sex M___ F ___ Birthdate ______________ Age _____ Breed ___________________________
Color __________________________
Neutered/Spayed?
Yes ___ What age? ______ No ___
Pet Insurance? Yes ____ Company ____________________________________________ No ___
Please check any symptoms or problems you’ve noticed with your pet:
___ Allergies
Microchip #___________________________________________________
___ Appetite Loss
___ Gagging
___ Sneezing
___ Behavioral Changes
___ Gums Bleeding
___ Thirst
___Breathing Problems
___ Limping
___ Urination Increase
___ Coughing
___ Loss of Balance
___ Vomiting
___Depression
___ Scooting
___ Weakness
___ Diarrhea
___ Scratching
Other _______________________
___ Eye Disorders
___ Shaking Head
____________________________
Authorization
I hereby authorize the veterinarian to examine, prescribe for, or treat the above pet. I
assume responsibility for all charges incurred in the care of the animal. I understand
that ALL PROFESSIONAL FEES ARE DUE AT THE TIME OF SERVICE. We accept cash
or the following credit cards: VISA, MasterCard, American Express, Discover or Care
Credit.
_________________________________________________________
__________________
Signature of Responsible Party (Must be at least 18 years of age)
Date
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