New Client Information Form

Home > New Patient Center > Online Forms > Welcome Form - New Patients

Welcome Form - New Patients

This is the form to fill out if you are visiting us for the first time. Please fill out this form and click the "Submit Form" button which will automatically send your information to us so we can prepare for your visit. If you are unsure as to a vaccine date or other information, write "unknown". We look forward to welcoming you to our family of clients.

Date: *

First Name *

Last Name *

Significant Other: If none say none *

Street Address *

City: *

State *

Zipcode *

Home Phone *

Work Phone *

Driver's License #: *

State where issued: *

Expiry Date: *

Email Address: *

How did you hear about us?

Emergency Contact Name: *

Emergency Phone #: *

There is room to enter info on 2 cats.

Cat # 1:

1. Cat Name *

1. Please select gender: *

1. Cat Breed *

1. Cat Color *

1. D.O.B. / Age *

1. Please Select *

1. At what age was neuter or spay performed? *

1. For What Purpose Was This Cat Obtained?

1. Other Purpose

1. Please Select

1. Date Last FVRCP vaccine given: *

1. Date Last Rabies given: *

1. Date Last FIP given: *

1. Date Last Leukemia given: *

1. Date Last FIV given: *

1. Date Last Bordatella given: *

1. Any known drug reactions, allergies, health or behavior problems? *

1. If yes, please explain:

CAT #2:

2. Cat's Name

2. Cat's Breed

2. Cat's Color

2. Cat's D.O.B. / Age

2. Please Select Gender

2. Please Select

2. If Neutered or Spayed, At What Age?

2. Where did you obtain this cat?

2. Other

2. For What Purpose Was This Cat Obtained?

2. Date Last FVRCP vaccine given?

2. Date Last Rabies Vaccine Given?

2. Date Last FIP vaccine given?

2. Date Last Leukemia vaccine Given?

2. Date Last FIV vaccine given

2. Date Last Bordatella Vaccine Given?

2. Please Select

2. Any known drug reactions, allergies, health or behavior problems?

2. If yes, please explain.

Additional Comments:

Policies

If your cat requires hospitalization, the adult owner shall give written permission to the Doctor to perform the necessary treatments. A minimum deposit of one half the estimated cost, or $50.00, whichever is greater, shall be left with the receptionist. ACCOUNTS ARE PAYABLE IN FULL AT THE TIME YOUR KITTY IS RELEASED FROM THE HOSPITAL. VISA, MasterCard, Discover, and American Express are accepted in addition to cash or checks. Care Credit is also available. There is a $25.00 returned check charge. Non-Payment for any reason will result in the account being submitted for collection and you agree to pay the full amount plus the cost of collection. FAILURE TO PAY FOR ANY REASON COULD IMPAIR YOUR CREDIT RATING!

I have read and agree to the above policy. *

Enter the verification code in the box below.