New Client Form — Graham Animal Hospital

New Client Form
Thank you for trusting us with the care of your pet! Please complete this form prior to your first appointment to assist us with patient intake.

Client Name

First Name

Last Name

Phone

(###)

###

####

Email

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Is anyone other than yourself authorized to make medical decisions or approve treatment(s) for your pet(s)? If yes:

Name

First Name

Last Name

Phone

(###)

###

####

Pet Name

Breed

Coat Colour

Date of Birth (or Age if not known)

Sex

Male (Intact)

Female (Intact)

Male Neutered

Female Spayed

If you have multiple pets, please enter their information below:

Previous Medical History

What is the name of your previous vet and can we contact them for records?

Have you contacted us regarding your pet other than filling out this form?

Yes

No

If not... What can we help you with today?

Social Media

Within the context of our business & pet health, we would like to use some images and/or information regarding your pet(s). Do you give us permission for your pet to participate on our social media sites?

Yes

No

Financial Agreement & Authorization

By submitting this form, I hereby authorize Graham Animal Hospital to examine, treat, and prescribe medications to my animal(s). I assume responsibility for all charges incurred in the care of my animals. I also understand that payment is DUE at the time of service. We accept payment by cash, Visa, Mastercard, Debit, or e-transfer.

I acknowledge the above information