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New Client Information Form

Client Information

Note: if there is a field not applicable to you, please fill in with N/A.

Date(Required)

Home Phone(Required)

Email(Required)

Owner's Name(Required)

First

Last

Owner's Cell Phone(Required)

Spouse/Other

First

Last

Address(Required)

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country

Employer

Employer Telephone #

Emergency Contact Person

First

Last

Local Telephone #

How did you first hear about us?(Required)

Yellow Pages

Brochure/Mailing

Internet

Other

Is there anyone we can thank?

Patient Information

Species

Canine

Feline

Name(Required)

Breed(Required)

Color(Required)

DOB (age)(Required)

Sex

Male

Female

Altered

Yes

No

Distemper(Required)

Rabies(Required)

Other Vax(Required)

Is your pet(s) currently protected against heartworm disease?(Required)

Yes

No

Is your pet(s) currently protected against fleas/ticks?(Required)

Yes

No

I, the undersigned, authorize the veterinarian(s) and staff employed by Old Mill Veterinary Hospital to examine, prescribe for and treat accordingly up to and including medical surgical procedures for the patient/s specifically described and identified above.

I assume responsibility for all charges incurred for services rendered to the patient/s.

Also, I understand payment is due when services are rendered. Deposits may be required for some services.

There are additional fees assessed for non-payment, returned checks and accounts sent to collection. I understand and agree to pay these fees.

Signature(Required)

Date(Required)

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