Form for New Clients | North Texas Veterinary Clinic

New Client Form

Step 1 of 4

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Owner/Caregiver's Name(Required)

First

Last

Address(Required)

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country

Cell Phone(Required)

Home Phone

Work Phone

Email(Required)

Spouse/Significant Other's Name

First

Last

Spouse/Significant Other's Phone Number

How did you hear about us?

Internet

Humane Society

Gateway Church Directory

Drove By

Personal Recommendation – see below

Other

Personal Recommendation

Whom may we thank?

Pet's Name(Required)

Species(Required)

Canine (Dog)

Feline (Cat)

Gender(Required)

Neutered Male

Spayed Female

Male

Female

Unsure

Breed(Required)

Color/Markings(Required)

Date of Birth or Approx. Age(Required)

Microchip Number

If known/applicable

List any medications your pet is currently taking (including heartworm/flea and tick prevention)

What food(s) do you feed your pet?

List any medical procedures your pet has had

Has your pet ever had a reaction to a vaccine? If so, which ones – please explain

List any allergies your pet has

List any current or previous medical conditions your pet has/has had

List any concerns you have about your pet's health

Please tell us any other information we may need to know about your pet (1).

If you are bringing in more than one new patient, you will be directed to our additional pet form at the end of this one.

The form can also be found here: https://northtexasveterinaryclinic.com/new-client-form-additional-pets/

In CASE OF AN EMERGENCY, and you are unreachable, please designate someone whom we may contact(Required)

Emergency Contact Name

Relationship to Owner(Required)

Emergency contact number(Required)

I hereby authorize North Texas Veterinary Clinic to receive, prescribe for and provide medical treatment for all animals I or my agent present. I agree and understand that payment for all services must be rendered at the time services are provided.(Required)