New Client/Patient Form ; Please fill out this form before your visit Please enable JavaScript in your browser to complete this form.Client InformationOwner's Name *FirstLastPrimary Phone *What type of phone is this number? *CellHomeWorkSecondary PhoneWhat type of phone is this number?CellHomeWorkSpouse/Co-Owner's NameFirstLastSpouse/Co-Owner's Primary PhoneWhat type of phone is this number?CellHomeWorkSpouse/Co-Owner's Secondary PhoneWhat type of phone is this number?CellHomeWorkAddress *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeEmail *Patient InformationPet's Name *Species *DogCatAge/Date of Birth *Breed *Color *Sex *MaleMale (neutered)FemaleFemale (spayed)Is your pet currently on heartworm/flea/tick preventative? *YesNoIf yes, what brand? *Does your pet have any history of vaccine reactions or drug allergies? *YesNoIf yes, please explain *Has your pet had any previous bloodwork performed? *YesNoIf yes, when? *Vaccine InformationDate next Rabies is due *Date next Distemper is due *Date next Heartworm testing is due *Date next Kennel Cough is due *Date next Feline Leukemia is due *Date next Fecal exam is due *I understand that all fees are due at the time services are rendered. Please indicate which method you will be using to pay for your upcoming visit. *CashCheckVisa/MasterCardDiscoverCareCreditIf you would like more information about CareCredit, please ask one of our receptionists or visit www.carecredit.comI am the legal owner or representative of the legal owner of the animal being presented for treatment, and am over the age of 18 years. I assume responsibility for all charges incurred in the care of this animal. I agree to pay for these charges at the time of service and understand that a deposit may be required for surgical treatment. *I have read and understandPhoto Release ConsentI grant Vergennes Animal Hospital and its employees the right to take photographs of me and/or my pet upon request and to copyright, use, and publish in print or electronically. *I authorizeI DO NOT authorizeHow did you hear about us? *OnlineDrove byPrevious clientDoctor referralClient referralOtherWhom may we thank for the referral? *If other, please specify *Signature *Clear SignatureDate *NameSubmit Contact Call: 802.877.3371 Fax: 802.877.6259 Email: info@vergennesah.com Temporary Office Hours Monday-Friday: 8:00 AM - 5:00 PM Address 20 Main Street Vergennes, VT 05491 Click here for directions.
