New Client Form Date Date Format: MM slash DD slash YYYY Owner's NameSpouse/OtherDriver’s License # (if paying by check):Address Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Primary Phone Number:Mobile Phone:Spouse/Other/Work Phone:Email Address How would you prefer we communicate with you about your pet?PhoneEmailTextIn case of EMERGENCY, please callPhone Number:HOW DID YOU HEAR ABOUT US?Previous ClientFacebookClinic SignNewspaperInternetFriend/FamilyReferred by: (so we can thank them!):PAYMENT INFORMATION We are happy to provide an estimated cost for treatment plans upon request. All professional fees are due at the time services are rendered. Compassionate Care Veterinary Clinic accepts: Cash, Personal Checks (providing DL#), Visa/MasterCard, American Express, Discover Card or CareCredit for payment. To prevent the spread of infectious diseases and parasites; hospitalized patients and pets in the clinic for boarding or grooming must be current on all vaccines and free of internal and external parasites. I authorize the doctor to provide vaccines and parasite control as needed for my pet. I authorize Compassionate Care Veterinary Clinic to photograph my pet for marketing purposes and publish those photos in any form. Thank you for allowing us to care for your pet! Please feel free to contact us at 319-483-5049 oremail us at CompassionateCareWaverly@gmail.com with any questions or to schedule /reschedule your pet’s appointment.SignatureDate Date Format: MM slash DD slash YYYY ANIMAL MEDICAL HISTORYNamePET #1PET #2PET #3Species (cat, dog, other)PET #1PET #2PET #3BreedPET #1PET #2PET #3ColorPET #1PET #2PET #3Male or FemalePET #1PET #2PET #3Spayed/NeuteredPET #1(Yes/No)PET #2(Yes/No)PET #3(Yes/No)Chronic Health ConcernsPET #1PET #2PET #3Current Medication(s)PET #1PET #2PET #3Diet (What type & amount of food)PET #1PET #2PET #3Previous Animal Medical History: Clinic Name or DVM Name & Phone number if known:Comments:
