New Client Form

Save time at your first appointment. Complete your required new client form online before your visit.

New Client Form

Please fill out this form as completely and accurately as possible so we can get to know you and your pet(s) before your visit.

Pet Owner Information

Owner Name *

First

Last

Preferred Phone *

Email *

Other Phone

Co-Owner Name

Co-Owner Phone

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Emergency Contact Name

Emergency Phone

How did you hear about us?

Pet Information

Pet Name

Species

Age or Date of Birth

Male or Female

Neutered or Spayed

Breed

Coat Color

Where can we request previous records?

Informed Consent

I am the owner/authorized agent for the pet(s) listed on this form. I hereby authorize Peninsula Pet Clinic to examine, prescribe for, and treat the above described pet(s). I assume responsibility for any services/products provided in the care of this animal. I understand that these charges will be paid at the time of release and that a deposit may be required for necessary treatment and/or hospitalization. All new clients shall pay a deposit equal to the amount of a regular exam fee for each pet of the initial exam. Our clinic accepts cash, credit/debit cards, and CareCredit. Checks are not accepted.

I have also read and understand the New Client Cancellation and No-Show Policy and the Prescription Refill Request Policy for the clinic.

Signature *

Clear Signature

Date *

Name

New Client Form

New Client Form

Pet Owner Information

Pet Information

Informed Consent

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