New Client Form





Client Information

First Name:
Last Name:
Spouse/Significant Other:
  Address
Street:
City:
State:
Zip Code:
  Phone Numbers
Home:
Work:
Cellular:
   
Email address:
Driver’s License Number:
Expiration Date:
Your Employer:
Spouse’s Employer:
Occupation:
Spouse’s Occupation:
How did you hear of our hospital?

 

Patient Information

Name:
Species (indicate one):  Dog Cat Rabbit Rat Mouse Guinea Pig Bird
Other:
Breed:
Birth Date:
   Male Female
   Spayed Neutered
How many other animals in your household?
 
Has your pet had any previous illness or surgeries?
   Yes No
Describe:
Is your pet currently on any medications?
   Yes No
What medications?
Has your pet had any vaccines in the last 12 months? (Please indicate which):
Dogs:  DHLP Parvo Rabies Bordetella Corona Giardia Rattlesnake
 
Cats:  Feline Leukemia FDVRCC Rabies FIP Giardia

 

Permission to Treat/Hospital Policy and Release

 I authorize the American Veterinary Hospital, and the professional staff of the American Veterinary Hospital to examine, perform diagnostics, and treat my companion animal. I understand that the practice of veterinary medicine is not an exact science, and acknowledge that no guarantees have been made to me as to the results of the treatment. I absolve the American Veterinary Hospital and its staff of any and all liabilities associated with the examination of my animal, and the diagnosis and treatment of its condition. I agree that I am responsible for the payment of all charges on my account for these services and that the fee for all services is due and payable at the time of the office visit. An estimate of fees for services is available by request.

Check to confirm submission.

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