New Client Form Date MM slash DD slash YYYY Owner's Name Spouse/Other Driver’s License # (if paying by check): Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest 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? Phone Email Text In case of EMERGENCY, please call Phone Number:HOW DID YOU HEAR ABOUT US? Previous Client Facebook Clinic Sign Newspaper Internet Friend/Family Referred 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 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:
