New Client Form - Kenmore Veterinary Hospital

Client Information

Date*

Owner's Name*

Home Address*

Primary Phone Number*

Alternative Phone Number

Email Address*

Place of Employment

Work Phone Number

Spouse/Partner/Co-Owner Name

Spouse/Partner/Co-Owner Phone Number

Emergency Contact Name

Emergency Contact Phone Number

Do you have pet insurance? If yes, what is the name of the pet insurance?

How did you hear about us?*

Whom can we thank?

Pet Information

Pet Name*

Species*

Cat
Dog

Breed*

Color/Markings*

Birthday/Age*

Sex*

Male
Female

Is your pet spayed/neutered?*

Yes
No
I don't know

Pet Medical History

Any known allergies?

Any chronic health problems?

Is your pet microchipped?*

Should your pet be muzzled?*

Has your pet been seen by a veterinarian previously? If yes, please fill in the name of the clinic. If no, please type "No."*

Reason for today's visit or any other questions/comments.

Authorization

We may need to contact you about your pet’s health, please consent by selecting the best method(s) of communication:*

Home Address (Mail)
Primary Phone Number
Work Phone Number
Text Message

Permission to share your records with Other Hospitals/Emergency/Specialty?

Permission to share your records with Groomers/Daycare?

Permission to share your records with Pet Insurance?

Media Consent

I grant to Kenmore Veterinary Hospital, its representatives and employees the right to take photographs of me and/or my pet, and to copyright, use and publish the same in print and/or electronically. I agree that Kenmore Veterinary Hospital may use such photographs of me and/or my pet with or without my name and for any lawful purpose, including but not limited to publicity, illustration, advertising, and web content.

Authorization

I do hereby certify that I am the owner, or assuming responsibility, financial or otherwise, for the animal being presented to Kenmore Veterinary Hospital for the treatment of care. I hereby consent and authorize Kenmore Veterinary Hospital to receive, prescribe for or treat, as indicated, this animal presented. It is thoroughly understood that I assume all risks. I agree, if appropriate, to pick up this animal at the designated date and time agreed to by myself and Kenmore Veterinary Hospital. If in the event that the animal is not picked up, there will be a notice of 10-days to come to claim the animal or it will be considered abandoned. The animal will be held in the manner that is considered to be most appropriate for the animal and the hospital. It is understood that I am not released from costs associated with the care of the pet. We do not bill and all fees are due when services are rendered. Deposits are required for all hospitalized patients. Our Hospital only accepts cash, personal checks (driver’s license required), Visa/MasterCard, American Express, Discover Card, Scratchpay, and Care Credit. I understand that if I do not pay my balance in full, that I am responsible for all statement fees, finance charges, and attorney/collection fees.

Name

This field is for validation purposes and should be left unchanged.