Sheys Veterinary Hospital - New Client Form

First Name:*

Last Name:*

Address:*

Street Address City State ZIP

Home Phone:

Work Phone:

Cell Phone:*

Email*

Method of payment today Payment is required at the time of service. For your convenience, we accept major credit cards including American Express, CareCredit, cash, or check (with a valid driver’s license). Please check one*

How much information do you want to be given about your pet’s health?

I want a full explanation—anything and everything.

I want a brief explanation—just the important stuff.

I just want to know if there’s anything I need to do—keep it simple.

Consent You will be asked to sign a health plan confirming authorization of treatment after a tentative diagnosis. The details of treatment, the risks of treatment, and/or the risk of not treating will be explained to you.*

I consent

Pet Name:*

Age/Birthday:

Species (cat, dog, etc.)*

Breed

Color

Sex*

Spayed/neutered?*

Does your pet have allergies?*

If yes, what?*

Has your pet ever had a reaction to vaccines or medications?*

If yes, what?*

List any major surgeries your pet has had:

List any behavior problems we need to be aware of:

List any foods and treats you give your pet:

Please list any person(s) other than yourself authorized to act as agent for your pet(s) or receive information regarding your pet(s) health:

Please list any other information you believe we should know about your pet(s):

Do we have permission to contact your previous veterinarian to obtain records for your pet?*

If No, please bring any records you have with you to your pet’s first appointment.

If yes, please list your pet’s previous veterinarian:

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