New Client Form Welcome to our practice! Please complete this form before your next visit. Please enable JavaScript in your browser to complete this form.Owner's Name *FirstLastPreferred pronounsAddress *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeHome PhoneCell PhoneWhich number is best to reach you? *HomeCellCan you receive text messages? *YesNoEmail *Owner's BirthdayWe need this information in case we have to send a controlled substance home. Add a Co-Owner? *YesNoName *FirstLastPreferred pronounsHome PhoneCell PhoneReason for leaving your current veterinary practice *Previous Vet:Previous Vet's Phone NumberHow did you hear about us?Drove ByGoogleFacebookYelpOtherReferralIf Other, please explain.Whom should we thank for referring you? Do you have an appointment scheduled? *YesNoIf you do not have an appointment scheduled, please schedule an appointment by clicking here.Appointment Date & Time *DateTimePET HEALTH HISTORYPet's Name *Sex *MaleFemaleNeutered/Spayed? *YesNoBreed *Color *Birthdate or Age *Current MedicationsPlease bring and give any medical records/vaccine records to the receptionists to make copies.DIET AND ENVIRONMENTWhat food does the patient currently eat? *Amount & Frequency? *Is your pet on any dietary supplements? *YesNoIf so, what kind and what dosage? *Does your pet consume table food? *YesNoPlease explain: *Is your pet primarily indoor or outdoor? *IndoorOutdoorAre there any other animals in the household? *YesNoPlease describe: *Do you have your pet groomed or boarded outside of your home? *YesNoIf so, how often? *PAST HISTORYHas your pet had any prior illnesses, accidents, or surgeries? *YesNoPlease explain:Is your pet aggressive or fearful around strangers? *YesNoPlease explain: *Is your pet on heartworm or flea/tick preventatives? *YesNoHow frequently? *Year-RoundSeasonallyPlease list any other medications or supplements your pet receives. Does your pet have any known allergies to any medications? *YesNoIf yes, please list: *Has your pet ever had a reaction to any vaccines? *YesNoIf yes, please list and explain: *Do you want to add another pet? *YesNoPet's Name *Sex *MaleFemaleNeutered/Spayed? *YesNoBreed *Color *Birthdate or Age *Current Medications Please bring and give any medical records/vaccine records to the receptionists to make copies.What food does patient currently eat? *Amount & Frequency? *Is your pet on any dietary supplements? *YesNoIf so, what kind and what dosage? *Does your pet consume table food? *YesNoPlease explain *Is your pet primarily indoor or outdoor? *IndoorOutdoorDo you have your pet groomed or boarded outside of your home? *YesNoIf so, how often? *Has your pet had any prior illnesses, accidents, or surgeries? *YesNoPlease explain:Is your pet aggressive or fearful around strangers? *YesNoPlease explain: *Is your pet on heartworm or flea/tick preventatives? *YesNoHow frequently? *Year-RoundSeasonallyPlease list any other medications or supplements your pet receives.Does your pet have any known allergies to any medications? *YesNoIf yes, please list: *Has your pet ever had a reaction to any vaccines? *YesNoIf yes, please list and explain: *OFFICE POLICIESTo allow for ample time for all patients and surgical procedures, Claremont Veterinary Hospital operates primarily by appointment. We request all our clients be on time for scheduled appointments and procedures. If you are 15 minutes late to your appointment, you may be asked to reschedule your appointment. We do take emergencies; however, these services may be subject to a higher fee schedule. For your convenience, we offer limited same-day appointments for urgent care sick patients. They fill up fast, so we recommend calling first thing in the morning. For your protection, and that of others, pets should be properly restrained by a leash or carrier upon arrival. If your pet requires special accommodations, please give us a call when you arrive so we can assist you and your pet. If you must cancel an appointment, we ask for 24 hours’ notice. For surgical appointments, we ask for a 48-hour cancellation notice. We accept cash, debit, or all credit cards. We also offer CareCredit. We would be more than happy to fill your prescriptions or have your food orders ready for pick-up. Please call ahead or use our website to process refills. Please allow 24-48 hours for prescription refills. Special orders or controlled substances may require longer. I hereby authorize the veterinarian to examine, prescribe for, or treat the above described pet. I assume responsibility for all charges incurred in the care of this animal. *I have read and agree.I understand that payment is ALWAYS DUE IN FULL at time of service. A deposit of 50% of the treatment plan may be required before treatments or hospitalization of your pet. I recognize that financial concerns should be discussed PRIOR to examination and treatment. *I have read and agree.I understand there are limited new client slots due to the overwhelming demand for veterinary care. By checking this box, I am committing to using Claremont Veterinary Hospital as my primary care veterinarian. A $65 exam fee deposit will be required to hold your first appointment. *I have read and agree.Do we have your permission to share your pet’s image and story on our social media, website, and other forms of related media? *YesNoI authorize my emergency contact (other than myself) to pursue treatment if I am unavailable. Your emergency contact must be an adult over the age of 18. *I have read and agree.Emergency Contact *FirstLastEmergency Contact Phone *SignatureClear SignatureDate *File Upload Click or drag files to this area to upload. You can upload up to 5 files. CommentSubmit