New Client Registration Form

Owner's Name

Name*

First Last

Main Phone #*

Is this a cell phone #*

Yes
No

Co-owner's Name & Contact #

Name

First Last

Main Phone #

Is this a cell phone #

Yes
No

Address

Address*

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

Email*

Enter Email Confirm Email

How did you find out about our practice?

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

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

What food does your pet eat?

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

Do you already have an appointment booked at Companion Animal Hospital?

Yes
No

If yes – please list the date of appointment

Permission to use my pet's photo on their medical chart (Photo will be taken at pet's first appointment)*

Yes
No

I hereby grant Companion Animal Hospital permission to use my Pet's photo on its clinic software for my pet's chart identifying photo.

Charges & Responsibility*

I confirm responsibility as described here

I assume responsibility for all charges incurred in the care of my pets. I also understand that all fees will be paid at the time of release and that a deposit may be required for some medical and surgical treatments. I am aware that payment methods accepted include: Cash, Debit, Visa and MasterCard.

Owner's Name

Co-owner's Name & Contact #

Address

Pet Information

LOCATION

HOURS