Client Information Record

Name *

First Name

Last Name

Partner/Other Name

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone (Mobile) *

(###)

###

####

Phone (Home)

(###)

###

####

Phone (Work)

(###)

###

####

If necessary, may we contact you at work?

Yes

No

Emergency Contact Name

First Name

Last Name

Emergency Contact Phone

(###)

###

####

How did you hear about our clinic?

Hospital Sign

Website

Phone Book

Personal Referral

Other

I feel my pet is another member of our family

I feel my pet is just a pet

I want the best medical care; please recommend anything you feel will optimize my pets' health.

I want good medical care for my pet, but there is a limit to what I am able to have done.

I want you to perform only the services that I request.

I want to learn as much as I can, please explain in detail what has been done for my pet.

I would prefer you just summarize what has been done for my pet or what is needed.

I prefer to be present when my pet is examined and treated.

I do not need to be present when my pet is examined and/or treated.

Date of Birth

MM

DD

YYYY

Sex

Male

Female

Altered (spayed/neutered)?

Yes

No

Date of Last Vaccinations

MM

DD

YYYY

Phone

(###)

###

####

Date of Last Dental Cleaning

MM

DD

YYYY

Date of Birth

MM

DD

YYYY

Sex

Male

Female

Altered (spayed/neutered)?

Yes

No

Date of Last Vaccinations

MM

DD

YYYY

Phone

(###)

###

####

Date of Last Dental Cleaning

MM

DD

YYYY

Date of Birth

MM

DD

YYYY

Sex

Male

Female

Altered (spayed/neutered)

Yes

No

Date of Last Vaccinations

MM

DD

YYYY

Phone

(###)

###

####

Date of Last Dental Cleaning

MM

DD

YYYY

Are any of the following a concern to you in your pet's behavior? Please Check

Excessive Barking

House Breaking

Excessive Itching/Scratching

Overly Rambunctious/Scratching

Biting

Smell

Shedding

Problems Around Children

Straying from Home

Eliminating/Marking/Spraying in the House