New Client Information
Thank you for giving us the opportunity to care for your pets. So that we may become better acquainted, please complete the following:
Owner's Name(s): *
Owner's Address
Owner's City, State & Zip
Phone: *
Other phone:
Email: *
How did you hear about our hospital? *
Required
Referred to us?
Please let us know who referred you to CPH so we may thank them!
Please let us know who your previous veterinarian was so we may contact them on your behalf and obtain your pet's records. *
By entering this information you are giving CPH permission to obtain your pet's medical records.
Pet #1's name: *
Please enter your pet's personal information
Species: *
Required
Date of Birth: *
If unknown, please select an estimated date of birth
MM
/
DD
/
YYYY
Breed/Color: *
i.e. Rottweiler, black and tan
Is your pet spayed/neutered? *
Does your pet have any allergies? Are they on a special diet? *
Please be specific.
Has your pet had a serious illness or surgery in the past? *
Is your pet on any medications? If so, please list: *
Is your pet on preventatives (monthly heartworm, flea/tick)? *
How does your pet handle new situations and people? *
Does your pet have any sensitive parts of their body they do not like being touched (i.e., ears, legs)?
Has your pet needed medications to help ease the stress of going to the vet? If yes, which? *
Pet #2's name:
Please enter your pet's personal information
Species:
Please select your pet's species:
Date of Birth:
If unknown, please select an estimated date of birth
MM
/
DD
/
YYYY
Breed/Color:
i.e. Rottweiler, black and tan
Is your pet spayed/neutered?
Does your pet have any allergies? Are they on a special diet?
Please be specific.
Has your pet had a serious illness or surgery in the past?
Is your pet on any medications? If so, please list:
Is your pet on preventatives (monthly heartworm, flea/tick)?
How does your pet handle new situations and people?
Does your pet have any sensitive parts of their body they do not like being touched (i.e., ears, legs)?
Has your pet needed medications to help ease the stress of going to the vet? If yes, which?
Pet #3's name:
Please enter your pet's personal information
Species:
Date of birth:
If unknown, please select an estimated date of birth
MM
/
DD
/
YYYY
Breed/Color:
i.e. Rottweiler, black and tan
Is your pet spayed/neutered?
Does your pet have any allergies? Are they on a special diet?
Please be specific.
Has your pet had a serious illness or surgery in the past?
Is your pet on any medications? If so, please list:
Is your pet on preventatives (monthly heartworm, flea/tick)?
How does your pet handle new situations and people?
Does your pet have any sensitive parts of their body they do not like being touched (i.e., ears, legs)?
Has your pet needed medications to help ease the stress of going to the vet? If yes, which?
I am responsible, and agree to pay in full, the total charges for services rendered at the time of discharge and any fees incurred for collection of said charges. I understand that fees are based on treatment deemed necessary at the time of exam, treatment, or admission and that the estimated fee may change by the administration of treatment, medication, surgery, or diagnostic test. By signing this form, I agree that Companion Pet Hospital may use photographs/videos of me and my pets for publicity, illustration, advertising, and web content. *
Please type your name below to acknowledge that payment is due at time of service -- we accept cash, check, all major credit cards, Care Credit, and Scratchpay.
Please select today's date *
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Time
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