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New Client Form

This document is a client/pet information form for Lake Mary Veterinary Clinic. It collects contact information for the pet owner including name, phone numbers, address, and driver's license or SSN. Information is also collected on up to two pets, including name, species, sex, breed, color, microchip number, indoor/outdoor status, birthdate, and vaccination history. The form notes that payment is due at time of service and authorizes the veterinary clinic to provide necessary treatment, with the client assuming financial responsibility.

Uploaded by

Sharon Burgess
Copyright
© Attribution Non-Commercial (BY-NC)
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Download as PDF, TXT or read online on Scribd
Download as pdf or txt
16 views1 page

New Client Form

This document is a client/pet information form for Lake Mary Veterinary Clinic. It collects contact information for the pet owner including name, phone numbers, address, and driver's license or SSN. Information is also collected on up to two pets, including name, species, sex, breed, color, microchip number, indoor/outdoor status, birthdate, and vaccination history. The form notes that payment is due at time of service and authorizes the veterinary clinic to provide necessary treatment, with the client assuming financial responsibility.

Uploaded by

Sharon Burgess
Copyright
© Attribution Non-Commercial (BY-NC)
Available Formats
Download as PDF, TXT or read online on Scribd
Download as pdf or txt
Download as pdf or txt
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Lake Mary Veterinary Clinic

Client/Pet Information
Todays Date _________________
Owners Name _______________________________________ ________________________
Phone (
)__________________
Co-Owner ___________________________________________________________________
Phone (
)__________________
Address__________________________________________________________
E-mail address ______________________________SSN____________________________
Drivers License # ___________________________________ STATE ______ EXP. _____
DAYTIME PHONE NUMBERS ARE VERY IMPORTANT TO US!
Work (

) _________________ Cell (

) _________________

Name of Pet: ______________________________________ Male / Female (circle one)


Dog / Cat / Rabbit / Bird / Other: _______________________ Neutered / Spayed
Breed __________________________________________ Color ______________________
Microchip Number: ___________________________________________________
Indoor _______ Outdoor ________ Birth Date/Age _______________
Vaccination History (provide dates if known)
Distemper _____________ Rabies _______________ Leukemia ______________
Bordetella _______________ Heartworm Check ______________
Name of Pet: ________________________________________Male / Female (circle one)
Dog / Cat / Rabbit / Bird / Other: _______________________ Neutered / Spayed
Breed __________________________________________ Color ______________________
Microchip Number: ___________________________________________________
Indoor _______ Outdoor ________ Birth Date/Age _______________
Vaccination History (provide dates if known)
Distemper _____________ Rabies _______________ Leukemia ______________
Bordetella _______________ Heartworm Check ______________
** PAYMENT IS EXPECTED AT THE TIME SERVICES ARE RENDERED **
We accept Cash, Checks, Visa, Master Card, Discover and Care Credit.
I, the undersigned owner or authorized agent of the above admitted patient, hereby
authorize the doctors of Lake Mary Veterinary Clinic to administer such treatment as is
necessary and to perform procedures therapeutically and/or diagnostically. I further
understand that no guarantee of successful treatment is made. I also assume financial
responsibility for all charges incurred, and agree to pay all such charges at the time of
release. I understand that unpaid balances over 30 days are subject to a monthly 1.5%
finance charge.
Signature of owner/agent_______________________________ Date _________

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