New Client Form

Owner's Information

Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

Type

Secondary Phone

Type

What is the best time of day to contact you?

No Preference
Daytime
Evening

Additional Contact Person*

Additional Contact Person Phone Number*

Employer's Name

Employer's Address

Street Address Address Line 2 City State ZIP Code

PAYMENT POLICY

All 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

Check all that may apply

Referral

How did you become aware of Telford Veterinary Hospital?

If a Personal Recommendation, who referred us? (so we can show our thanks)

PET INFORMATION

Pet's Name*

Species*

Cat
Dog

Breed*

Color*

Date of Birth (Approximate)*

Sex*

PET QUESTIONNAIRE

Which of the following best describes your pet?*

Family Member
Child's Pet
Backyard Pet

Where does your pet spend their time?*

Indoor only
Outdoor only
Both

Who 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?*

Yes
No

Do you use a Groomer or Boarding Kennel?*

Yes
No

Do you travel, hike, camp or hunt with your pet?*

Yes
No

Are you currently using any type of flea preventive?*

Yes
No

Does your pet have a microchip?*

Yes
No

It 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?*

Yes
No

The 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)?*

Yes
No

HEALTH RECORDS

*DOG OWNERS - Please indicate below to the best of your knowledge the last date your dog has had the following

Rabies Vaccine

Distemper Vaccine

Kennel Cough Vaccine

Lyme Booster

Heartworm Test

Fecal Test

*CAT OWNERS Please indicate below to the best of your knowledge the last date your cat has had the following

Rabies Vaccine

Distemper Vaccine

Leukemia Vaccine

Leukemia Test

Fecal Test

Do you consent to photos of your pet being utilized in hospital promotions and on Social Media?*

Yes
No

Please include any additional information regarding your pet that you feel may be important to us.

THANK YOU FOR THE OPPORTUNITY TO CARE FOR YOUR PET!!!

Telford Veterinary Hospital