New Client Form

Thank you for giving us the opportunity to care for your pet(s).  So that we may become better acquainted, please complete the following:

CLIENT INFORMATION

Date:  

Name: Spouse's Name:

Address:  City:

State: Zip:

Phone: Work Phone:

Spouse's Work Phone:  Cell Phone:

Spouse's Cell Phone:

Place of Employment:

E-Mail Address:

How would you prefer to receive vaccine reminders for your pet(s)? Mail E-Mail

Yes , I hereby consent to release my pet(s) medical information to the following (borading kennel, referral veterinarian, relatives, friends).

No, please contact me prior to releasing my pet(s) medical information.

Please list name(s) of people you authorize to consent for treatment of your pets.

1)
2)
3)
4)

All Fees Are Due At the Time Services Are Rendered
Please indicate choice of payment.  
Cash/Check
Visa
MasterCard
Discover
American Express
CareCredit

How did you become aware of our clinic?
Drove By
Yellow Pages
Location
PetCo
Referral

Personal Reccomendation (Whom may we thank?)


PATIENT INFORMATION
                   

	Pet #1	Pet #2	Pet #3
Name:
Breed:
Date of Birth Or Aprox. Age:
Color:
Sex: Spayed or Neutuered?

Has your pet had previous vaccinations?   Yes   No
Please indicate when and where they were given.


Any previous serious ilnesses or surgeries?


Any allergies to vaccinations or medications?


Is your pet on any speial diets or medications?

I assume full financial responsibility for my pet's care.  I understand that I must pay in full at the time medical services are completed.  I have been advised that any charges revealed during post care audits will be invoiced in a timely manner and remain my financial responsibility.

Signature:
Date:

2504 Mall Dr. Eau Claire, WI 54701. 715-835-5011. Fax: 715-835-0993. Site Designed and Hosted by Wireless Wisconsin LLC.