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:

Dr. Mr. Mrs. Miss Ms.

Owner's First and Last Name:

Co-Owner's First and Last Name:

Street Address:
City:	State: Zip

Home Phone # (with area code):

Occupation:

Employer:

Work Phone # (with area code):

Cell Phone # (with area code):

E-mail Address:

E-mail address will be used for occasional

newsletters or reminders; it will not be sold or shared.

Pet Information

Pet Name:

Type of Pet:
Breed:
Color:
Sex:
Spayed/Neutered:
Date of Birth:

Are the pet's vaccines current? Yes No Not Sure

Do you have the pet's medical records? Yes No

Second Pet Name:

Type of Pet:
Breed:
Color:
Sex:
Spayed/Neutered:
Date of Birth:

Are the pet's vaccines current? Yes No Not Sure

Do you have the pet's medical records? Yes No

Third Pet Name:

Type of Pet:
Breed:
Color:
Sex:
Spayed/Neutered:
Date of Birth:

Are the pet's vaccines current? Yes No Not Sure

Do you have the pet's medical records? Yes No

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

Yes No

Name of Former Veterinary Practice?

May we request a transfer of records?

Yes No

How did you learn about us?

Phone Book Internet Search/Web site Location

SPCA Breeder I am a Former Client

Pet Store (name):

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

Friend or relative (If so, who?):

Other (Please specify):

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.

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

DATE: TIME:

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:

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Pet lover's since 2/14/05

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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