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NEW CLIENT REGISTRATION FORM
Name _____________________________________________________________________________________________________
Last First Middle Initial
Address____________________________________________________________________________________________________
Street City, State, Zip Code
Email__________________________________________ Phone______________________ Emergency #_____________________
Employer_________________________________________________________________ Work Phone________________________
Spouse Or Co-Owner’s Name______________________________________________ __
Co-Owner’s Employer______________________________________________________ Work Phone_____________ ______ __ __
How Did You First Hear Of Us? _________________________________________________________________________________
(Person’s Name, Yellow Pages, Sign, Newspaper, Internet, Other)
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PET NO. 1 PET NO. 2
Name_____________________________________________ Name_____________________________________________
Age_______ Birth Date_______________________________ Age_______ Birth Date_______________________________
Species □ Cat □ Dog Other___________________ Species □ Cat □ Dog Other__________________
If Feline, Where Does Your Pet Live? If Feline, Where Does Your Pet Live?
Indoor □ Outdoor □ Indoor/Outdoor□ Indoor □ Outdoor□ Indoor/Outdoor□
Breed_______________________ Sex___________________ Breed_______________________ Sex__________________
Neutered? ___________________ Date__________________ Neutered? ___________________ Date__________________
Color_____________________________________________ Color_____________________________________________
Where Last Shots Obtained____________________________ Where Last Shots Obtained____________________________
Where Was The Pet Obtained From? ____________________ Where Was The Pet Obtained From? ___________________
Long Term Problems? (Medical Or Behavioral)_____________ Long Term Problems? (Medical Or Behavioral)____________
__________________________________________________ __________________________________________________
Current Medications, If Any____________________________ Current Medications, If Any____________________________
__________________________________________________ __________________________________________________
Reason For Visit_____________________________________________________________________________________________
__________________________________________________________________________________________________________
List Names And Types Of Any Other Pets You Own__________________________________________________________________
I hereby authorize the Vermont-New Hampshire Veterinary Clinic to examine, prescribe for, or treat the above described pet(s). I assume responsibility for all charges incurred in the care of this animal. I also understand that these charges will be paid at the time of release, and that a deposit may be required for surgical treatment or hospitalization.
Signature of Owner or Authorized Agent_____________________________________________ Date_________________________
Method of Payment: □ Cash □ Check □ MC/VISA □ Discover □ Care Credit
**Please print this form and fill it out to bring to your pet's first appointment, or fax it our office.** Our fax # is (802) 257-0649.
Also, if possible, please fax or mail medical records prior to your appointment. You can request to have records faxed directly to us from your current veterinarian. This will help us to stay on schedule and provide your pet with our best possible care.
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