New Client/Patient Form

Client Information

Owner's Name *

First

Last

Primary Phone *

What type of phone is this number? *

Cell
Home
Work

Secondary Phone

What type of phone is this number?

Cell
Home
Work

Spouse/Co-Owner's Name

First

Last

Spouse/Co-Owner's Primary Phone

What type of phone is this number?

Cell
Home
Work

Spouse/Co-Owner's Secondary Phone

What type of phone is this number?

Cell
Home
Work

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Email *

Patient Information

Pet's Name *

Species *

Dog
Cat

Age/Date of Birth *

Breed *

Color *

Sex *

Male
Female

Spayed/Neutered? *

Yes
No

Is your pet currently on heartworm/flea/tick preventative? *

Yes
No

If yes, what brand? *

Does your pet have any history of vaccine reactions or drug allergies? *

Yes
No

If yes, please explain *

Has your pet had any previous bloodwork performed? *

Yes
No

If yes, when? *

Vaccine Information

Date 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. *

If you would like more information about CareCredit, please ask one of our receptionists or visit www.carecredit.com

I 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 understand

Photo Release Consent

I 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 authorize
I DO NOT authorize

How did you hear about us? *

Whom may we thank for the referral? *

If other, please specify *

Signature *

Clear Signature

Date *

Please fill out this form before your visit

Client Information

Patient Information

Vaccine Information

Contact

Hours

Address