Client Sheet

Client Information Sheet

Current promotion: A one time gift of $25 off services on your first appointment
Completed form must be presented at time of appointment, for discount to apply.
This ad may not be used for diet, lab work, products or used in conjunction with other coupons or promotions.
Promotion expires June 30, 2017

Name:__________________________ Home Phone:_____________________ Cell #:____________________

Your Employer: _____________________________________ Work #:______________________ EXT_____

Email:______________________________________ Which # do you prefer to be called at:  home     cell        work

Address:_________________________________City:_______________________State:________Zip:__________

Spouse/Alternate Contact:______________________________ Phone #:_______________________

Employer: ____________________________Work #:___________________________Ext #___________

Thank you for choosing us for your pets health care! Please take a moment to let us know how you discovered our clinic.
We love referrals! If we were recommended to you, please let us know their name, so we can thank them appropriately.

Referred by:______________________ ( ) Yellow Pages ( ) Clinic Sign ( ) Website ( ) Internet Search
If you are happy with our services, We would appreciate your recommendation to others!

Our clinic operates on a cash basis and does not do any billing.
Payment for services or products is required at each visit.We accept cash, Debit, Visa, Mastercard, & Care Credit.

By signing, I am accepting financial responsibilityfor treatment of my pet(s).

Signature:_____________________________________________________ Date:___________________

Pet #1

Name: ____________________

Canine or Feline DOB or age: ___________

Breed: ________________________________

Color: _________________________________

Sex: M or F , Spayed or neutered? Yes or No

Vaccine Status/Dates:_______________________

Any Medications or Supplements?_____________

Insurance:____________________________

Name of previous Veterinarian:___________________________________________

Pet #2

Name: ____________________

Canine or Feline DOB or age:___________

Breed: _____________________________

Color: ______________________________

Sex: M or F , Spayed or neutered? Yes or No

Vaccine Staus/Dates:_____________________

Any Medications or Supplements?_____________

Insurance:_____________________________