The House Call Vet
New Client Information Form
Owner Name
Address
City
Zip
Email Address:
Home phone
Cell phone
Work phone
Spouse's name
Spouse's work phone
Owner's Driver's License number (required if paying with check)
How did you find out about our service?
please select one
referral
internet search
other
Pet's name
Breed
Sex
male
female
Color
Date of birth. Estimate if unknown.
Please check one:
Neutered
Spayed
Neither
Date of last vaccinations
Is your pet currently on a special diet or medication?
Yes
No
If so, what?
List any known drug allergies
Please list any other pets you have and the dates of their last vaccinations. Please submit a separate form for each additional pet that requires an examination.
Payment is due at time of services. Please check your method of payment.
Cash
Check
Discover
MasterCard
Visa
create a form