New Client Registration Form

Owner's Name

Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Date of Birth*

Day-Time Phone*

Evening Phone

Mobile Phone

Email*

Enter Email Confirm Email

Co-owner's Name & Contact #

Name

First Last

Phone

How did you find out about our practice?*

If Other, please specify:

If Personal Referral, is there someone we can thank for this referral?

Please use this area to give us any other relevant information about yourself or your family

Pet Information

Pet's Name*

Species*

or if other species

Breed (if known)

Color

Date of Birth or Age (if known)

Special Identification (tattoo, microchip, etc.)

Sex

Previous Veterinary Practice (if any)*

Previous Veterinarian (if any)

What vaccines were given at this time

Is your pet on any medication or supplement?

Yes
No

If Yes, please list the medication or supplement

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

Would you like to add another pet?

Yes
No

Pet #2

Pet's Name*

Species*

or if other species

Breed (If Known)

Color

Date of Birth or Age (If Known)

Special Identification (tattoo, microchip, etc.)

Sex

Previous Veterinary Practice (if any)*

Previous Veterinarian (if any)

What vaccines were given at this time?

Is your pet on any medication or supplement?

Yes
No

If Yes, please list the medication or supplement

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

Would you like to add another pet?

Yes
No

Pet #3

Pet's Name*

Species*

or if other species

Breed (If Known)

Color

Date of Birth or Age (If Known)

Special Identification (tattoo, microchip, etc.)

Sex

Previous Veterinary Practice (if any)*

Previous Veterinarian (if any)

What vaccines were given at this time?

Is your pet on any medication or supplement?

Yes
No

If Yes, please list the medication or supplement

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

Cancellation / Missed Appointments Policy*

We ask that our clients provide a minimum of 24-hour notice for appointment rescheduling or cancellation. If 3 or more appointments are missed in a 6-month period, we require a deposit for exam cost ($53) in advance for future appointment scheduling, which the provider has right to charge for any additional missed appointments.

First Last

Appointment Date and Time*

Appointment Date and Time

Appointment Date Time

Signature*

By entering your name below, I agree to pay in full for all treatments provided to my pet(s) by Old Towne Animal Hospital. I understand that all fees are due at the time of service. Any charges left unpaid will be sent to collections.

First Last

Date

Monday	7:30am – 6:30pm
Tuesday	7:30am – 6:30pm
Wednesday	7:30am – 6:30pm
Thursday	7:30am – 6:30pm
Friday	7:30am – 6:30pm
Saturday	7:30am – 6:30pm
Sunday	7:30am – 6:30pm

Contact Us

New Client Registration Form