New Client Form

To speed check-in at your pet’s first appointment, please complete and submit this form. Thanks!

Client Name (Owner)*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Cell Phone*
Home Phone
Spouse
First Last
Spouse Phone
Email*
- (Please check if you do not wish to receive clinic updates and appointment confirmations via e-mail)
How did you hear about our clinic?
- Drive by
- Google
- Yellow Pages
- Website
- OurTown
- Money Mailer
- Shelter
- Equitrade
- Barter Company
- Tradebank
- Family/Friend
- Other
Family/Friend
Other
Pet Information
Name*
Age/DOB
Color
Species*
- Dog
- Cat
Breed
Sex
- Neutered Male
- Spayed Female
- Intact Male
- Intact Female
Microchip?
- Yes
- No
Microchip Number
Brand of Food
Heartworm/Flea Control
Date of Last Vaccinations
Date Format: MM slash DD slash YYYY
Where?
Add another pet?
- Yes
- No
Name*
Age/DOB
Color
Species*
- Dog
- Cat
Breed
Sex
- Neutered Male
- Spayed Female
- Intact Male
- Intact Female
Microchip?
- Yes
- No
Microchip Number
Brand of Food
Heartworm/Flea Control
Date of Last Vaccinations
Date Format: MM slash DD slash YYYY
Where?
ALL PAYMENTS ARE DUE AT THE TIME OF SERVICES RENDERED
I understand the above statements and agree to all terms therein. I agree that all the information is correct to the best of my knowledge. The signature below gives Family Pet Hospital permission to any and all necessary treatment (in case of an emergency) when the owner cannot be contacted prior to necessary services.
Signature*
Date*
Date Format: MM slash DD slash YYYY
We accept cash, checks, care credit and all major credit cards. A Wellness Financing Plan is available for major procedures exceeding $200.