New Client Information – Delta Veterinary Clinic

Owner's Name

Name*

First Last

Date of Birth*

MM

DD

YYYY

Address*

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

Day-Time Phone*

Evening Phone*

Mobile Phone

Email*

Enter Email Confirm Email

Place of Employment

Work Address

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

DL or SS Number*

Name

If not employed, relative not living with them.

First Last

Address

If not employed, relative not living with them.

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

Co-owner's Name & Contact #

Name

First Last

Phone Number #1*

Evening Phone Number*

How did you find out about our practice?

If Other, please specify:

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

Pet Information

Previous Veterinary Practice Phone Number

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*

Previous Veterinary Practice (if any)

Previous Veterinarian (if any)

Date of last vaccines (if known)

What vaccines were given at this time

Is your pet on any medication or supplement?

Yes
No

If Yes, please list the medication or supplement

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

Agreement to Terms of Services (See Below)**

I authorize treatment and or service for any animal I bring in and agree to pay all fees and charges for such treatment. I agree to pay ALL charges for my pet shown by statement, promptly upon presentment thereof. Charges shown by statement are agreed to be correct and responsible unless protested in writhing within 30 days. All fees are due at the time of service. However, in the event collection or legal action should be necessary to collect an unpaid balance due to medical service rendered fro my pet, I agree to pay the collection and reasonable attorney’s fee or other such cost as the courts determined proper. Do not sign this agreement before you read and agree to the conditions. You are entitled to a copy of the agreement at the time that you sign. Keep it to protect your legal rights. You must ask for a copy.

Yes
No

New Client Registration Form

Owner's Name

Co-owner's Name & Contact #

Pet Information

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