New Client FormOwner's InformationName* First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Phone*TypeCellHomeWorkFaxSecondary PhoneTypeCellHomeWorkFaxAdditional Contact Person*Additional Contact Person Phone Number*Email* PAYMENT POLICYAll fees are due at the time services are rendered. If you have any questions about projected costs, please let us know. We will be happy to provide you with an Medical Care Plan outlining costs.Preferred Method of Payment Cash Check Credit CareCreditCheck all that may applyReferralHow did you become aware of Telford Veterinary Hospital?Drive bySocial Media (Facebook, Instagram, etc)Community EventPampered PetsGoogle Search/WebsitePersonal recommendationIf a Personal Recommendation, who referred us? (so we can show our thanks)PET INFORMATIONPet's Name*Species*CatDogBreed*Color*Date of Birth (Approximate)*Sex*Intact MaleNeutered MaleIntact FemaleSpayed FemaleUnknownPET QUESTIONNAIREWhich of the following best describes your pet?*Family MemberChild's PetBackyard PetWhere does your pet spend their time?*Indoor onlyOutdoor onlyBothWho was your previous Veterinarian?*Has you pet had any serious illnesses or surgeries?*Does your pet have any allergies to vaccinations or medications?*Is your pet on any special diets or medications?*Would you like to be present during the treatment of your pet?*YesNoDo you use a Groomer or Boarding Kennel?*YesNoDo you travel, hike, camp or hunt with your pet?*YesNoAre you currently using any type of flea preventive?*YesNoDoes your pet have a microchip?*YesNoIt would be helpful to the treatment of your pet if we could obtain his/her previous medical records. May we contact your previous Veterinarian to obtain them?*YesNoThe health status of your human family may effect the medical recommendations for your pet's preventative healthcare. Is anyone in your household immune compromised (Cancer, Diabetes, Hepatitis or HIV positive)?*YesNoDo you consent to photos of your pet being utilized in hospital promotions and on Social Media?*YesNoCAPTCHA
