802.877.3371
[email protected]
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New Client/Patient Form
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Please fill out this form before your visit
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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
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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.
*
Cash
Check
Visa/MasterCard
Discover
CareCredit
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?
*
Online
Drove by
Previous client
Doctor referral
Client referral
Other
Whom may we thank for the referral?
*
If other, please specify
*
Signature
*
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Date
*
Comment
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Contact
Call:
802.877.3371
Fax:
802.877.6259
Email:
[email protected]
Temporary Office Hours
Monday-Friday:
8:00 AM - 5:00 PM
Address
20 Main Street
Vergennes, VT 05491
Click here for directions.