New Client Form Owner & Pet Information Name Spouse Street Address City State Zip Mailing Address (if different) City State Zip Primary Telephone Cell Telephone Place of Employment Work Telephone Driver’s License Referred by Email Previous Veterinarian Veterinarians Telephone 1st Patient Name Date of Birth Species Dog Cat Bird Other Breed Sex Male Female Unknown Altered Yes No Color and Markings Current MedicationsCurrent Medications Allergies or Long Term Medical Problems 2nd Patient Name Date of Birth Species Dog Cat Bird Other Breed Sex Male Female Unknown Altered Yes No Color and Markings Current MedicationsCurrent Medications Allergies or Long Term Medical Problems *** AUTHORIZATION *** I hereby authorize the veterinarian to examine, prescribe for, or treat the above described pet(s). To the best of my knowledge, I affirm the following pet(s): 1.) no known or diagnosed allergies to vaccines, 2.) Pebblebrooke Animal Hospital uses the finest vaccines available, however, a vaccine reaction is possible, but rare. 3.) Should my pet(s) become ill due to vaccine, I will not hold Pebblebrooke Animal Hospital or its affiliates responsible. 4.) Being aware of these facts, I give my permission to Pebblebrooke Animal Hospital to treat and/or vaccinate my pet(s) as seen fit by myself and the medical professionals of Pebblebrooke Animal Hospital. 5.) If applicable, I will not give HEARTWORM PREVENTATIVE without NEGATIVE test results. I assume responsibility for all charges incurred in the care of my animals. I also understand that these charges will be paid at the time services are rendered. Owner agrees to pay all charges incurred as a result of any visit to or care rendered to Owner’s at Pebblebrooke Animal Hospital at the time said services are rendered. In the event that the said charges are not paid upon rendering services, the owner agrees to pay all costs, fees and expenses, including the reasonable attorney fees, incurred as a result to collect charges. *** Please Note: Pebblebrooke Animal Hospital reserves the right to use any photos, letters, cards, reviews or documents submitted to or taken within the facility of Pebblebrooke Animal Hospital on our website, social media, or in print. *** Send
