Garbizo Animal Clinic - New Client Form

PERSONAL INFORMATION

Owner Last Name

Owner First Name

Co-Owner Last Name

Co-Owner First Name

Mailing Address

Home Phone

Cell Phone

Work Phone

Co-Owner Phone

DL Number

EXP

MM slash DD slash YYYY

Co- Owner DL Number

EXP

MM slash DD slash YYYY

Email Address

Co-Owner Email Address

Other Authorized Contacts (Name and Phone Number)

How did you find us?

Other

PATIENT INFORMATION #1

Name

Species

Breed

Color

Untitled

Male

Female

Spayed/Neutered

Yes

Date of Birth

MM slash DD slash YYYY

Microchip Number

Is your pet current on Vaccinations?

Yes

If Yes, please provide Name / Contact number of previous veterinarian:

Please list current illnesses or previously diagnosed conditions

Any Special Requirements Needed?

Current Diet?

How much?

How Often?

Current Medication(s)?

Preventions

Does Your Pet have Insurance?

Yes

If Yes Provider Name

Policy Number

PATIENT INFORMATION #2

Name

Species

Breed

Color

Untitled

Male

Female

Spayed/Neutered

Yes

Date of Birth

MM slash DD slash YYYY

Microchip Number

Is your pet current on Vaccinations?

Yes

If Yes, please provide Name / Contact number of previous veterinarian:

Please list current illnesses or previously diagnosed conditions

Any Special Requirements Needed?

Current Diet?

How much?

How Often?

Current Medication(s)?

Preventions

Does Your Pet have Insurance?

Yes

If Yes Provider Name

Policy Number

VIDEO/PHOTO RELEASE

Signature

Date

MM slash DD slash YYYY

By signing above, I give Garbizo Animal Clinic permission to use my or my pet's picture and/or video on the website, social media, and in various other advertising methods for promotional purposes.

STATE LAW AND INSURANCE REQUIREMENTS MANDATE THAT ALL DOGS & CATS MUST BE CURRENT ON RABIES VACCINATION. Vaccinations can be updated at the time of your appointment if they are not current

TREATMENT AUTHORIZATION

Signature

Date

MM slash DD slash YYYY

By signing above, I authorize the medical staff at Garbizo Animal Clinic to provide medical treatment to my pet(s). We will do our best to keep you informed of the costs of diagnostics and therapies prior to them being performed, but if you would like a written estimate prior to service please inquire. Payment is due on the day services are rendered. We accept cash, all major credit cards, Care Credit, ScratchPay, and checks (on a case-by-case basis).