Stringtown Animal Hospital New Client Form
We are pleased to welcome you to our practice. Please take a few minutes to fill out this form as completely as you can.
If you have any questions we'll be glad to help you. We look forward to working with you in maintaining your pet's health.
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PET INFORMATION
Pet's Name:___________________________ Dog Cat Age/Birth date:___________________ Male Female
Breed:______________________ Color:____________________ Neutered/Spayed Yes No At What Age?:_______________
Where did you obtain this pet? Friend Breeder Pet Shop Humane Society
At What Age Was This Pet Obtained? ______ Years / Months Diet (Kind of Pet Food): _______________________________________
Pet's History (Please Check all that your pet has received):
DHLP (Distemper - Dog) _________ Feline Leukemia Test (Cat) _________ Rabies (Dog/Cat) ____________
Parvovirus (Dog) __________ FVRCP Respiratory Vaccine (Cat) __________ Dentistry ____________
Heartworm Test (Dog) _________ Feline Leukemia Vaccine (Cat) ___________
Date of Last Vaccination: __________________________
Name of Monthly Heartworm Preventive (Sentinel, Revolution): __________________________
Date Last Heartworm Preventive Was Given: ____________________________________
Please describe the following:
Has Your Pet Had Any Prior Illness: _____________________________________________________
Has Your Pet Had Any Prior Surgery: ___________________________________________________
Reason for today's visit: _______________________________
Name of previous Vet: __________________________________________
May we obtain Records? Yes No
CLIENT INFORMATION
Name: ____________________________________________________________________________ Date: _______________________
Social Security # ____________________________ Driver's License: _________________________________
Address: _______________________________________________________________________________________________________
City: _______________________________ State:______________ Zip:______________ Home Phone:_______________________
Cell Phone: ______________________ Email Address: ______________________________________
Employer: _______________________________________ Occupation: ___________________________________________________
Business Address: ______________________________________________________________ Business Phone:_____________________
Spouse or Co-Owner: ___________________________________________________________ Home Phone:_______________________
Cell Phone: _____________________________ Email Address:____________________________
Business Address:_______________________________________________________________ Business Phone:____________________
PAYMENT
We will gladly prepare a written estimate of service fees if you desire (please ask the receptionist or technician).
All professional fees are due at the time services are rendered. In case of extensive medical or surgical procedures a deposit
will be required and the remainder of the balance is due at discharge
How did you learn about our practice? __________________________________________________________________________________
Signature of client responsible for pet (s):_____________________________________________ Date:_____________________________