New Client Information Form

Pet Information

Pet's Name*

Species*

Breed (if known)*

Color*

Date of Birth or Age (if known)*

Sex*

Previous Veterinary Practice (if any)

Previous Veterinarian (if any)

Does your pet have allergies or drug reactions?*

Yes
No

If Yes, please list the allergies and reactions

Are there any current or past medical conditions of which we should be aware?*

Yes
No

If Yes, please comment on the condition(s) and indicate if they are current or past conditions

Do you have a 2nd pet?*

Yes
No

2nd Pet's Name

Species

Breed (if known)

Color

Date of Birth or Age (if known)

Sex

Does your pet have allergies or drug reactions?

Yes
No

Are there any current or past medical conditions of which we should be aware?

Yes
No

If Yes, please list the allergies and reactions

If Yes, please comment on the condition(s) and indicate if they are current or past conditions

Do you have a 3rd pet?

Yes
No

3rd Pet's Name

Species

Breed (if known)

Color

Date of Birth or Age (if known)

Sex

Does your pet have allergies or drug reactions?

Yes
No

Are there any current or past medical conditions of which we should be aware?

Yes
No

If Yes, please list the allergies and reactions

If Yes, please comment on the condition(s) and indicate if they are current or past conditions

I, the undersigned, do hereby consent and agree that Rocklin Road Animal Hospital, its employees, or agents have the right to take photo, videotape, or digital recordings of my above-listed pet(s) and release all rights to exhibit this work in print and electronic form publicly or privately. I also understand that Rocklin Road Animal Hospital is not responsible for any expense or liability incurred as a result of my, or my pet(s) participation in any photos and/or recordings.*

Accept
Decline

I hereby authorize the staff at Rocklin Road Animal Hospital to examine, prescribe for and treat the above-described pet(s). I assume responsibility for all charges incurred in the care of this/these animal(s). I also understand that all charges will be paid at the time of release of my pet and that a deposit may be required before treatment.*

Accept

Signature of Owner/Agent*

First Last

Date

New Client Information Form

Step 1 of 2

Owner/Agent:

Spouse

Pet Information

CONTACT INFORMATION

HOURS OF OPERATION

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