New Patient/Client Information

WELCOME TO Southwest Vet

Thank you for giving us the opportunity to provide quality care for your pet(s).

Date*
MM slash DD slash YYYY
Owner's Name*
Spouse/Other
Address*
Street Address City State / Province / Region ZIP / Postal Code
Home Phone*
Work Phone*
Cell Phone*
Email Address*
Employer's Name & Address
In case of EMERGENCY, please call*
at phone number*
How did you first hear of our hospital?
- Brochure
- Hospital Sign
- Facebook
- Google
- Yelp
- Individual
- Other
If Individual; someone we may thank?
Photo and Sharing Authorization: We love treating your pets and enjoy the time you allow us to spend with them. On occasion, we would like to capture these moments in photo/video. These photos may be emailed to you as an update on their status/progress, used on our website, or shared on social media sites such as Facebook. Do you authorize us to photograph/video your pet for these purposes?*
- Yes
- No
PAYMENT IS DUE IN FULL AT THE TIME SERVICES ARE RENDERED
I understand that if I do not pay this account as agreed, the account is subject to costs of collection, attorney fees, and including interest (any balance that is carried over a period of 30 days will accrue a monthly finance charge of 1.5% or 18% per annum). Return check fee is $30.00 plus tax. I understand that the hospital staff will provide an estimate of current and anticipated charges any time I request one. I am requesting that veterinary care be provided for pets presented by me or my agents. I understand that I am financially responsible for all services provided.

To prevent the spread of infectious disease and parasites all in-patients, out-patients, boarders and grooming pets must be current on all vaccines and be free of parasites. I understand this to be the strict policy of the clinic and authorize the doctors to provide my pet or pets with vaccinations and parasite control as needed.
About Pet 1
Name*
Species (cat, dog, other)*
Breed*
Description (color)*
Age*
Date of Birth*
MM slash DD slash YYYY
Sex*
Neutered or Spayed*
Diet (kind of pet food)*
Hours Spent Outside Each Day*
Microchip Number
Temperament: Has your pet ever bitten anyone?*
Any other temperament concerns? Please explain.
VACCINATION & LAB HISTORY
(Dates Last Given)
(Dog) DHLPPC
(Dog) Bordetella
(Dog) Rabies
(Dog) Heartworm Test
(Dog & Cat) Heartworm Prevention
(Dog & Cat) Stool Check
(Cat) FVRCP
(Cat) Leukemia
(Cat) Rabies
(Cat) Feline Leukemia Test
(Cat) Feline Aids Test
Name and phone # of previous Veterinarian or Hospital for vaccination/medical history on your pet(s):
About Pet 2
Name
Species (cat, dog, other)
Breed
Description (color)
Age
Date of Birth
MM slash DD slash YYYY
Sex
Neutered or Spayed
Diet (kind of pet food)
Hours Spent Outside Each Day
Microchip Number
Temperament: Has your pet ever bitten anyone?
Any other temperament concerns? Please explain.
VACCINATION & LAB HISTORY
Dates Last Given
(Dog) DHLPPC
(Dog) Bordetella
(Dog) Rabies
(Dog & Cat) Heartworm Test
(Dog & Cat) Heartworm Prevention
(Dog & Cat) Stool Check
(Cat) FVRCP
(Cat) Leukemia
(Cat) Rabies
(Cat) Feline Leukemia Test
(Cat) Feline Aids Test
Name and phone # of previous veterinarian or hospital for vaccination/medical history on your pet(s):
Signature*
Date*
MM slash DD slash YYYY

New Patient/Client Information

WELCOME TO Southwest Vet

PAYMENT IS DUE IN FULL AT THE TIME SERVICES ARE RENDERED

About Pet 1

VACCINATION & LAB HISTORY

About Pet 2

VACCINATION & LAB HISTORY