New Client Form

New Client Form

Thank you for giving us the opportunity to care for your pet(s). So that we may become better acquainted, please complete the following:

Client Information:

Name:___________________________Spouse's Name________________________________

Address______________________________City___________State_______Zip____________

Phone_____________Work Phone________________Spouse's Work Phone_______________

Place of Employment_______________________________Best Time To Reach You _______

Driver's License #__________________Social Security #_____________________________

Email address_________________________________________________________________

Cell Phone #__________________________

All Fees Are Due At The Time Services Are Rendered

Personal Recommendation (Whom may we thank?)___________________________________

Please indicate choice of payment: Cash/Check Credit Card

Patient Information
	Pet #1	Pet #2	Pet #3
Name
Breed
Date of Birth
Color
Sex: Spayed/Neutered
Your Dog's Vaccination History:
Rabies
DHLP Parvo Corona
Bordetella
Lymes
Heartworm Test/Prevention?
Your Cat's Vaccination History:
Rabies
FVRCP-P-Leuk
FIP

Our pet(s) is/are Member of our family Child's Pet Backyard Pet

Any previous serious illnesses or surgeries?_________________________________________

Any allergies to vaccinations or medications?_______________________________________

Is your pet on any special diet or medication?______________________________________

Would you like to be present during treatment to your pet? Yes No

Do you have Veterinary Pet Insurance Yes No

Signature_________________________________________________

Please print this form, fill it out, and bring it to Wharton Vet Clinic with you on your first visit. We know your time is valuable and we are providing this online form to help expedite your vet clinic visit.