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New Client Registration Form for Pets

This document is a new client registration form for a veterinary clinic. It collects information such as the owner and pet's name, contact details, driver's license and social security numbers, pet vaccination history, current medications, symptoms, and reason for visit. The owner signs to permit examination and treatment of their pet and accepts financial responsibility for all incurred charges.

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3K views2 pages

New Client Registration Form for Pets

This document is a new client registration form for a veterinary clinic. It collects information such as the owner and pet's name, contact details, driver's license and social security numbers, pet vaccination history, current medications, symptoms, and reason for visit. The owner signs to permit examination and treatment of their pet and accepts financial responsibility for all incurred charges.

Uploaded by

api-405160881
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd

New Client Registration

Owner’s Name: __________________________ Spouse/Co-owner______________________________

Mailing Address: _______________________City: _______________State: _______Zip: _____________

Phone: __________________________ Email: _______________________________________________

Driver’s License Number: _________________________ State: _________ SSN: ____________________

Pet Information:

Name of Pet: ______________________________ (circle) Dog/Cat/Other______________

Birthdate: _______________ Microchip #: _______________ (Circle) Sex: Male/Female/Neutered/Spay

Breed: _____________________ Color: ____________________

Vaccination History: ____________________________________________________________________

Pet’s Current Medications: _____________________________________________________________

Please Check (x) any symptoms or problems you have with your pet.

 Behavior Problems  Scooting


 Bleeding Gums  Scratching
 Breathing Problems  Seems Depressed
 Bad Breath  Shaking head
 Coughing  Sneezing
 Eye Irritation  Excessive Thirst
 Diarrhea  Urination Increased
 Gagging  Vomiting
 Lack of Appetite  Weakness
 Limping Foot: _______  Other __________
 Loss of Balance
Reason for today’s visit: _________________________________________________________________

***PAYMENT IS DUE UPON COMPLETION OF SERVICE ***

I, the undersigned owner/authorized agent of admitted patient, herby permit the veterinarian to
examine, prescribe for, and treat my animal(s) or to perform procedures therapeutically and/or
diagnostically as deemed necessary. I further understand that it is not possible to guarantee the
successful outcome of any such procedure. I have read and accept responsibility for all charges incurred
in the care of the animal’s name above. This agreement is in force indefinitely form this unless I notify
Treasure Valley Veterinary Services in writing to the contrary. I understand that if I fail to pay as agreed,
legal action will be taken against me.

Signature of Owner/ Agent: ______________________________________________________________


New Client Registration

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