New Client Check In

If you would like to make an appointment, you can assist us to expedite your check in by submitting this form.

Thank you for your cooporation in letting us assist you.

Form - New Client

Name (required)
First Name (required)
Last Name (required)
Address (required)
Street Address (required)
City (required)
State/Province (required)
Zip/Postal Code (required)
,
Home Phone # (required)
Phone TypePhone Number (required)
E-Mail Address (required) :
Employer (required)

Work Phone # (required)
Phone TypePhone Number (required)
Second Owner
First Name
Last Name
Relationship to Owner :
Second Owner Employer

Second Owner Work Phone
Phone TypePhone Number
Pet's Name (required)

Type of Pet (required) :
Breed: (required)

Date of Birth or Age (required)

Color (required)

Sex: (required)
Male
Female

Neutered/Spayed (required)
Neutered
Spayed
Not Altered/Unknown

Any previous serious illnesses or surgeries? (required)

Any allergies to vaccinations or medications? (required)

Special diets or medications? (required)

Would you like to be present during treatment of your pet(s)? (required) :
Is your pet current on all vaccinations? (required) :
Please list the dates of your pet's last Rabies and Distemper vaccination.

Medical records at another veterinary Practice? (required)
Yes
No

Name of Former Veterinary Practice

May we request a transfer of records?
Yes
No

Former Veterinarian Telephone

Would you like us to call you to set up an appointment? (required) :
Reasons or conditions that prompted your visit? (required)

Special requests or conditions?

Please list any additional pets here

Please Read
I understand, by indicating I agree and submitting this registration, that I am responsible for any charges incurred by my pet while in the care of the doctors at Taylor Veterinary Hospital and that charges are due and payable at the time of service, unless other arrangements are made in advance. Any balance that is carried over a period of 30 days will accrue a monthly finance charge of 1.5% or 18% per annum. Any balance that I leave unpaid will be forwarded to Taylor Veterinary Hospital's collection agency, and will incur a 25% collection fee for which I am liable, in addition to monthly finance charges.
I have read this statement and - (required)
I Agree
I Disagree


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