New Client Form – Pacific Animal Hospital

Owner's Name

Day of Scheduled Appointment*

Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

County*

Day-Time Phone*

Evening Phone

Mobile Phone

Owner Social Security #

Owner Driver's Licence #

Place of Employment

Date of Birth*

Email*

Enter Email Confirm Email

Co-owner's Name & Contact #

Name

First Last

Phone

Co-Owner Social Security #

Co-Owner Driver's Licence #

Place of Employment

Date of Birth*

Consent

I agree that you have my permission to post pictures of my pet on social media.

How did you find out about our practice?

Drove by
Personal Referral
Internet Search / Website
Yellow Pages

If Other, please specify:

If Personal Referral, is there someone we can thank for this referral?

Please use this area to give us any other relevant information about yourself or your family

Pet Information

Pet's Name*

Species*

or if other species

Breed (if known)

Color

Date of Birth or Age (if known)

Special Identification (tattoo, microchip, etc.)

Sex

Date of last rabies vaccines (if known)

MM

DD

YYYY

Has your pet ever had a vaccine reaction?

Yes
No

Previous Veterinarian

Does your pet have an Instagram handle?

Does your pet have allergies or drug reactions?

Yes
No

If Yes, please list the allergies and reactions

Are there any current or past medical conditions of which we should be aware?

Yes
No

If Yes, please comment on the condition(s) and indicate if they are current or past conditions

Please use the following box to give us any other relevant information about your pet

Disclaimer*

I agree to pay for all fees at the time services are rendered. There is a $30.00 service charge for all returned checks. Any account that is 30 or more days past due may be sent to collections. If a default of this agreement occurs and/or in the attempt to collect money owed to Pacific Animal Hospital, I may also incur additional fees on my account that may include service charges, collection fees, attorney fees, court costs, interest, and any other charges associated with collecting money owed on my account. I have read the above and agree to the terms and conditions set forth herein.

I agree to the above statement

New Client Registration Form

Owner's Name

Co-owner's Name & Contact #

Pet Information