New Client Form Date Date Format: MM slash DD slash YYYY Owner's NameSpouse/OtherSocial Security #:Driver’s License #:Address Street Address City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Home Telephone:Work Phone:Spouse/Other/Work Phone:Cell Phones:Email Address Employer’s Name:Spouse Employer Name:How would you prefer we communicate about your pet?PhoneEmailCan we send you a text message reminder regarding your pet?YesNoIn case of EMERGENCY, please callPhone Number:HOW DID YOU HEAR ABOUT US?Previous ClientYellow PagesClinic SignNewspaperRadioTheater AdSignageFriend/FamilyReferred By:PAYMENT INFORMATION We will gladly give you a written ESTIMATE if you desire. Please ask our doctor or receptionist. ALL PROFESSIONAL FEES ARE DUE AT THE TIME SERVICES ARE RENDERED. For your convenience, we take cash, personal checks, Visa, MasterCard, and Discover. To prevent the spread of infectious diseases and parasites, hospitalized and boarded pets 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. 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 #3SexPET #1PET #2PET #3BirthdatesPET #1PET #2PET #3Existing Skin Conditions or AllergiesPET #1PET #2PET #3Chronic Health ConcernsPET #1PET #2PET #3Current MedicationPET #1PET #2PET #3Diet (What type & amount of food)PET #1PET #2PET #3Drug SensitivitiesPET #1PET #2PET #3Current on Heart Worm and Flea Products (if yes, what used)PET #1PET #2PET #3Last Fecal Exam & ResultPET #1PET #2PET #3Dental ConcernsPET #1PET #2PET #3Prior IllnessesPET #1PET #2PET #3Prior SurgeriesPET #1PET #2PET #3Spayed/NeuteredPET #1(Yes/No)PET #2(Yes/No)PET #3(Yes/No)VACCINATIONS (skip this section if you brought records along or transferred records from another clinic) DistemperPET #1PET #2PET #3BordatellaPET #1PET #2PET #3RabiesPET #1PET #2PET #3Other VaccinesPET #1PET #2PET #3Heartworm TestPET #1PET #2PET #3OtherPET #1PET #2PET #3Comments:
