New Client Form – All-Star Veterinary Clinic

Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Date of Birth *

Preferred Phone Number *

Who does this phone number belong to? *

Email *

Employer

Employer Phone Number

Add a secondary contact? *

Yes
No

Name *

First

Last

Relationship to Contact *

Address same as primary? *

Yes
No

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Preferred Phone Number *

Email

Employer

Employer Phone Number

How did you hear about us? *

Referring Vet's Name *

Please provide a first and last name. *

Please provide further detail. *

Pet's Name *

Type *

Dog
Cat

Gender *

Male
Female

Male pet is: *

Altered
Non-Altered

Female pet is: *

Altered
Non-Altered

Breed *

Color *

Age/Date of Birth *

Date of Last Vaccination *

Where did you get your pet? *

Adopted
Pet Store
Breeder
Other

Please provide further detail. *

From where? *

What store? *

Which breeder? *

Have you visited a previous vet clinic? *

Yes
No

Name of Previous Vet Clinic *

Previous Vet Clinic Address

Address Line 1

Address Line 2

City

State

Zip Code

Previous Vet Clinic Phone Number

Does your pet have a history of biting?

Yes
No

If yes, please explain

Any long term medical conditions?

Please list current medications.

Does your pet have any allergies? *

Yes
No

Please explain.

Do you have another pet? *

Yes
No

Pet's Name *

Type *

Dog
Cat

Gender *

Male
Female

Female pet is: *

Altered
Non-Altered

Male pet is: *

Altered
Non-Altered

Breed *

Color *

Age/Date of Birth *

Date of Last Vaccination *

Where did you get your pet? *

Adopted
Pet Store
Breeder
Other

Please explain. *

From where? *

What store? *

Which breeder? *

Have you visited a previous vet clinic? *

Yes
No

Name of Previous Vet Clinic *

Previous Vet Clinic Address

Address Line 1

Address Line 2

City

State

Zip Code

Previous Vet Clinic Phone Number

Does your pet have a history of biting?

Yes
No

If yes, please explain

Any long term medical conditions?

Please list current medications.

Does your pet have any allergies? *

Yes
No

Please explain. *

Do you have another pet? *

Yes
No

Pet's Name *

Type *

Dog
Cat

Gender *

Male
Female

Male pet is: *

Altered
Non-Altered

Female pet is: *

Altered
Non-Altered

Breed *

Color *

Age/Date of Birth *

Date of Last Vaccination *

Where did you get your pet? *

Adopted
Pet Store
Breeder
Other

From where? *

What store? *

Which breeder? *

Please explain. *

Have you visited a previous vet clinic? *

Yes
No

Name of Previous Vet Clinic *

Previous Vet Clinic Address

Address Line 1

Address Line 2

City

State

Zip Code

Previous Vet Clinic Phone Number

Does your pet have a history of biting?

Yes
No

If yes, please explain

Any long term medical conditions?

Please list current medications.

Does your pet have any allergies? *

Yes
No

Please explain. *

Do you have another pet? *

Yes
No

Pet's Name *

Type *

Dog
Cat

Gender *

Male
Female

Male pet is: *

Altered
Non-altered

Female pet is: *

Altered
Non-altered

Breed *

Color *

Age/Date of Birth *

Date of Last Vaccination *

Where did you get your pet? *

Adopted
Pet Store
Breeder
Other

From where? *

What store? *

Which breeder? *

Please explain. *

Have you visited a previous vet clinic? *

Yes
No

Previous Vet Clinic Name *

Previous Vet Clinic Address

Address Line 1

Address Line 2

City

State

Zip Code

Previous Vet Clinic Phone Number

Does your pet have a history of biting? *

Yes
No

If yes, please explain

Any long term medical conditions?

Please list current medications.

Does your pet have any allergies? *

Yes
No

Please explain. *

I hereby authorize All-Star Veterinary Clinic to use my pets' photographs, videos, and first name for the clinic's social media pages and website.

I hereby authorize the veterinarian to examine, prescribe for, or treat the above mentioned pet(s). I assume responsibility for all charges incurred in the care of this animal. I also understand that these charges will be paid for at the time of release and that a deposit may be requested for surgical treatment. *

I have read and understand.

I understand that typing my name in the box below constitutes a legal signature confirming that I acknowledge and agree to the above Terms of Acceptance. *