My Pets Vet - New Client Form

	New Client Information Form

New Client Form

After discussing your planned visit with a nurse or one of our receptionists, new clients should fill in the form below. If you would rather not send information over the internet, the form can be downloaded in two different formats. Please complete it in the comfort of your home before your pet's appointment. Filling the form out at home prevents a longer a stay in the reception area. Thank you!

Download printable versions here:

Owner's First and Last Name: *

Prefix

First

Last

Suffix

Co-Owner's First and Last Name: *

Prefix

First

Last

Suffix

Address:

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

Home Phone: *

###

####

Occupation:

Employer:

Work Phone:

###

####

Cell Phone:

###

####

E-mail Address:

E-mail address will be used for occasional newsletters or reminders; it will not be sold or shared.

Confirm Email: E-mail Address:

Pet Information

Please provide information about your pet here.

Pet Name: *

Type of Pet: *

Breed: *

Color: *

Sex: *

Spayed/Neutered: *

Pet's Date of Birth:

YYYY

I don't know my pet's age:

Unknown

Are the pet's vaccines current? *

Yes

Not sure

Do you have the pet's medical records?

Yes

Second Pet

Second Pet's Name:

Type of Pet: *

Breed: *

Color: *

Sex: *

Spayed/Neutered: *

Pet's Date of Birth:

YYYY

I don't know my pet's age:

Unknown

Are the pet's vaccines current? *

Yes

Not sure

Do you have the pet's medical records?

Yes

Third Pet

Third Pet's Name:

Type of Pet: *

Breed: *

Color: *

Sex: *

Spayed/Neutered: *

Pet's Date of Birth:

YYYY

I don't know my pet's age:

Unknown

Are the pet's vaccines current? *

Yes

Not sure

Do you have the pet's medical records?

Yes

Are the medical records for your pet(s) at another Veterinary Practice?

Yes

Name of Former Veterinary Practice?

May we request a transfer of records?

Yes

If you have already scheduled a visit with us, please enter the date and time of your appointment:

Appointment Time:

YYYY

AM/PM

Medical conditions or allergies

Briefly describe any medical conditions or allergies that your pet may have. You can elaborate on specific details during your appointment, if necessary. In addition, if there is anything else you would like to tell us, please enter your comments here:

Medical conditions or allergies

How did you learn about us?

Phone book

Internet Search/Web site

Location

SPCA

Breeder

I am a Former Client

Other

Pet Store (name):

Dr. Referral, (If so, who?):

Friend or relative (If so, who?):

PAYMENT IS DUE IN FULL AT THE TIME SERVICES ARE RENDERED

I understand that if I do not pay this account as agreed, the account is subject to costs of collection, attorney fees, and including interest (any balance that is carried over a period of 30 days will accrue a monthly finance charge of 1.5% or 18% per annum). Return check fee is $20. I understand that the hospital staff will provide an estimate of current and anticipated charges any time I request one. I am requesting that veterinary care be provided for pets presented by me or my agents. I understand that I am financially responsible for all services provided. By submitting this form I agree to the payment terms above.

WE ACCEPT THE FOLLOWING: CASH, CHECK, MASTER CARD, VISA.

WE CAN ARRANGE FOR CareCredit, ASK OUR RECEPTIONIST FOR DETAILS.

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My Pet's Vet is a full service veterinary clinic serving the greater Milwaukee area including Thiensville, Cedarburg, Grafton, Bayside, Fox Point, Brown Deer, River Hills, Glendale, Whitefish Bay Milwaukee, Mequon, Germantown. Gentel care for cats, dogs, birds, reptiles, rabbits, ferrets, chinchillas and other small mammals. mypetsvetonline.com