Client Intake Form

Your Name

Date

Address

City/Town

State/Province

ZIP/Postal Code

Country

Cell Phone

Home Phone

Work Phone

E Mail Address (required for us to send you your pet's X rays, medical/appointment reminders, relay important info, etc)

* = this sensitive information is encrypted and stored securely for your protection
**Driver’s License State/Number (required to write a check/to get certain meds)

State/Province

**Driver's License Number

**Your Date of Birth (required to get certain medication)

Whose DL#/date of birth is noted above? (please specify if more than one name is noted above as owner or info is not that of person noted above)

Other people (friends, family, pet-sitter) with permission to authorize treatment for your pet

How did you hear about us?

Is anyone in your home allergic to latex?

Yes

Is anyone in your home immunocompromised (HIV, cancer, organ transplant, etc)? This information will allow us tailor recommendations for your pet(s).

Yes

Is anyone who will be giving your pet medication allergic to any drugs?

Yes

If yes, what is that person allergic to?

Pet's Name

Dog or Cat?

Breed

Color

Male or Female?

Spayed / Neutered?

Date of Birth / Age

Multiple Pets? (Add below)