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Family Veterinary Clinic

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New Client Check In

If you would like to make an appointment, you can assist us to expedite your check in by submitting this form.

FAMILY VETERINARY CLINIC
New Client Information
 
Name____________________________Homephone__________________________
 
Address_________________________________City________________Zip_______
 
E-mail Address_______________Driver’s License (required)____________
 
Employer________________________Title/Occupation______________________
 
Work Phone________________WorkAddress____________________________
 
Spouse/Responsible Party____________________ E-mail________________
 
Employer________________________Title/Occupation______________________
 
Who may we thank for referring you?____________________________________
_________________________________________________________________
 
Pet Information
 
Pet’s Name___________________Sex______ Neutered: Y N Birthdate_____
 
Dog/Cat/Other? Breed_________________Color___________________________
 
Date of Last Vaccinations                               
Rabies___________ DHPP/DAP_______             RCCP/HCP_______
                                                                                         Fel Leukemia_____
Bordetella________                                                    FeLV/FIV Test____
Given at:_________________________________
 
Pet’s Name__________________Sex______ Neutered: Y N Birthdate______
 
Dog/Cat/Other? Breed__________________Color__________________________
 
Date of Last Vaccinations        
Rabies___________
DHPP/DAP_______                     RCCP/HCP_______
                                                          Fel Leukemia_____
Bordetella ________                   FeLV/FIV Test____
       Given at:_________________________________
 
Check one:
q I feel my pet is a member of the family.
q I feel my pet is just a pet.


Thank you for your cooporation in letting us assist you.

Form - New Client

Name & Email (required)
First Name (required)
Last Name (required)
Address (required)
Street Address (required)
City (required)
State/Province (required)
Zip/Postal Code (required)
,
Daytime Phone (required)
Phone TypePhone Number (required)
Evening Phone (required)
Phone TypePhone Number (required)
E-Mail Address :
Pet's Name (required)

Age: Years, Months

Type of Pet (required) :
Breed:

Sex: (required)
Male
Female

Neutered/Spayed
Neutered
Spayed

Are your pets vaccines current?
Do you have pets medical records?
Medical records at another veterinary Practice?
Yes
No

Name of Former Veterinary Practice

May we request a transfer of records?
Yes
No

Would you like us to call you for your appointment
Reasons or conditions that prompted your visit?

Special requests or conditions?

Please list any additional pets here

Please Read
I understand, by indicating I agree and submitting this registration, that I am responsible for any charges incurred by my pet while in the care of the doctors at Family Veterinary Clinic and that charges are due and payable at the time of service, unless other arrangements are made in advance. Any balance that is carried over a period of 30 days will accrue a monthly finance charge of 1.5% or 18% per annum. Any balance that I leave unpaid will be forwarded to Family Veterinary Clinic's collection agency, and will incur a 25% collection fee for which I am liable, in addition to monthly finance charges.
I have read this statement and -
I Agree
I Disagree


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Verification Code :
Enter the code you see in the graphic below in this box.
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