Client Information

Name *

First

Last

Additional Owner's Name *

First

Last

Email *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Primary Phone *

Secondary Phone

Your preferred way of contact? *

Call
Text

Do you already have an appointment scheduled?

Yes
No

Place of employment

Address of employer *

Address Line 1

Address Line 2

City

State

Zip Code

How did you find us?

“Everyone believes that they have the best pet, and none of them are wrong” We love to share our patients and their stories. Do we have permission to share your pet’s photo on our social media, website or other marketing materials?

Yes
No

View Our Facebook
View Our Instagram

Pet Information

Please help us get to know your pets, by providing some basic information:

Pet's Name

Species

Breed

Color

Date of Birth

How long owned?

Sex

Male
Female

Spayed/ Neutered

Yes
No

Cats: FeLv/ Fiv tested?

Yes
No

Prior Illnesses

Special Diet

Any known allergies

What parasite prevention do you currently use? (heartworm/ flea/ tick)

Current on vaccines? If so, where were they last given?

Please list all medications your pet is currently taking

Please upload your pet's records here

Click or drag a file to this area to upload.

You can upload up to 5 files.

Would you like to add information for another pet? *

Yes
No

Pet's Name

Species

Breed

Color

Date of Birth

How long owned?

Sex

Male
Female

Spayed/ Neutered

Yes
No

Cats: FeLv/ Fiv tested?

Yes
No

Prior Illnesses

Special Diet

Any known allergies

What parasite prevention do you currently use? (heartworm/ flea/ tick)

Current on vaccines? If so, where were they last given?

Please list all medications your pet is currently taking

Please upload your pet's records here

Click or drag a file to this area to upload.

You can upload up to 5 files.

Would you like to add information for another pet? *

Yes
No

Pet's Name

Species

Breed

Color

Date of Birth

How long owned?

Sex

Male
Female

Spayed/ Neutered

Yes
No

Cats: FeLv/ Fiv tested?

Yes
No

Prior Illnesses

Special Diet

Any known allergies

What parasite prevention do you currently use? (heartworm/ flea/ tick)

Current on vaccines? If so, where were they last given?

Please list all medications your pet is currently taking

Please upload your pet's records here

Click or drag a file to this area to upload.

You can upload up to 5 files.

Method of payment

Full payment is required at the time of services. Deposits are required on major medical/surgical or emergency cases where hospitalization is required. We accept: Cash, Credit & Check

Please choose your method *

Cash
Credit
Check

Would you like to keep a credit card on file for contactless payment? *

Yes
No

Please choose your card *

Visa
Master Card
American Express
Discover

We do not carry open accounts and do not accept payment plans. We can provide estimates before services are rendered.

Authorization

I hereby authorize the veterinarian to examine, prescribe for, or treat the above described pets. I assume responsibility for all charges incurred in the care of this animals. I also understand that these charges will be paid at the time of service and that a deposit may be required for treatment. To prevent the spread of infectious diseases and parasites, pets staying at our facility for hospitalization, boarding, daycare or grooming must be current on all vaccines. Pets staying with us must also be free of internal and external parasites. I authorize Animals R Special Veterinary Clinic to provide necessary vaccines, prevention or treatment to comply with these terms. *

I have read and agree

Signature *

Clear Signature

Date *

New Client Form

New Client Form

Client Information

Pet Information

Method of payment

We do not carry open accounts and do not accept payment plans. We can provide estimates before services are rendered.

Authorization

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Address

Contact Details

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