New Client Form

Certificate

$40.00 OFF NEW CLIENT EXAM

10% OFF ALL PET FOODS AND PET SUPPLIES

$10.00 OFF BOARDING VISIT

Offer applies to new clients only
No expiration date.

 

Date:
Owner's Name:
Spouse's Name:
Other's Name:
Email:
Address:
Apt #:
City:
State:
Zip:
Home Phone:
Cell Phone:
Work Phone:
Spouse/Other Phone Number:
Spouse Work Number:
Best Time to Reach by Phone:
In Case of Emergency Call:

Name
Phone

How did you become aware of our clinic? Who should we thank?
   

Patient Information

Name:
Nickname:
Species:
Color:
Breed:
Date of Birth:
Male/Female



Neutered/Spayed



Is your pet currently receiving any medications, if yes what?
Does your pet have any known allergies or has had any vaccine reactions, if yes please describe?
Dogs Only-Does your dog travel outside of Missouri?



Cats Only-Does your cat go outdoors (porch, patio, backyard, etc.)?



Pre Examination Questionnaire
Have you noticed the following abnormalities?

Diarrhea Frequent Urination
Limping Lethargy Not Eating
Scooting Licking Excessive Drinking
Sneezing Coughing Chewing
Scratching Hair Loss Lumps/Sores
Straining to Urinate Straining to Defecate    

Other

Payment Policy:
All Fees Are Due At The Time Services Are Rendered

For your convenience we accept payment by cash, check, debit, Visa, MasterCard and Discover. We also accept Care Credit and provide the applications for approval in our office. Ask a receptionist for more details.