New Client Form

Owner's Name *

First Name:

Last Name:

Address *

Street Address:

Address Line 2:

City:

State:

ZIP Code:

Contact Information *

Email:

Phone:

Emergency Contact Information *

First Name:

Last Name:

Phone:

Pet Information *

Pet Name:

Species:
CatDog

Sex:
Neutered MaleSpayed FemaleIntact MaleIntact Female

Breed:

Color:

Date of Birth:

Current Medications:

Current Diet:

Where did you get your pet from?

What environment does your pet live in? (i.e. Urban, city, suburban, etc.)

Do you have children or other animals at home? If yes, please list.

Add another pet?
YesNo

Previous Veterinarian:

Previous Veterinarian Phone Number:

By clicking this box, I do hereby grant permission to release any or all of the information contained in the medical records of my pets listed below to East Springfield Veterinary Hospital*

ACKNOWLEDGEMENT OF PAYMENT UPON RECEIPT OF SERVICES: I hereby authorize ESVH’s veterinarians and support staff to examine, prescribe for, and/or treat the above named pet(s). I assume financial responsibility for all charges incurred in the care of my pet(s). I also understand that payment in full is due when services are rendered.

Sign Below*:

Date*

VETERINARY MEDICAL RECORDS RELEASE: I, the undersigned, do hereby grant my permission to release any or all of the information contained in the medical records of those pets listed below to the following person and/or veterinary practice.*

Initial:

I authorize ESVH to photograph my pet(s) and exhibit pictures in the clinic’s reception area, on social media networks such as Facebook, and/or on our website.*

Initial:

Sign Below*:

Date*