New Client FormOwner Name* First Last Co-Owner Name First Last Pet Name*Pet Type*CatDogSex*Male (neutered)Female (spayed)Male (intact)Female (intact)Breed*Color*Pet DOB or Approx. Age*Last Rabies Vaccination*Any Long Term Problems?Please describe & indicate if listing multiple petsPrevious Records Available?*YesNoLocation of Previous RecordsPlease list contact information for previous records & indicate if listing multiple petsAdd a second pet?YesNo2nd Pet's Name First Last 2nd Pet TypeCatDogSexMale (neutered)Female (spayed)Male (intact)Female (intact)2nd Pet Breed2nd Pet Color2nd Pet DOB or Approx. Age2nd Pet Last Rabies VaccinationAdd a third pet?YesNo3rd Pet's Name First Last 3rd Pet TypeCatDogSexMale (neutered)Female (spayed)Male (intact)Female (intact)3rd Pet Breed3rd Pet Color3rd Pet DOB or Approx. Age3rd Pet Last Rabies VaccinationPhone*Email* Physical Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Mailing Address Same as PhysicalMailing Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican 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 RicoQatarRomaniaRussiaRwandaRéunionSaint 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 IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country *How did you hear about our clinic?WebsiteGoogleFacebook or InstagramFriend or FamilyFinancial Agreement*I am the owner of the animal or am responsible for it and have the authorization to execute this consent. I hereby authorize the treatment of this animal and performance of such medical, surgical, or therapeutic procedures you determine to be indicated and use of such anesthetics as you deem advisable. I understand that all professional fees are due at the time of service. It is agreed that past due accounts are subject to maximum allowed per month late charges, and in addition, all costs of collection including a reasonable attorney's fee. I agreePhoto Consent*I grant permission to use any photographs taken of myself or my pet, in any and all of its publications, including website and social media entries, without payment or any other consideration. I hereby authorize to edit, alter, copy, exhibit, publish or distribute this photo for purposes of publicizing your programs or for any other lawful purpose. In addition, I waive any right to royalties or other compensation arising or related to the use of the photograph. I hereby release rights to all claims, demands, and causes to action which I, my heirs, representatives, executors, administrators, or any other persons acting on my behalf of my estate have or may have by reason of this authorization. In signing this consent, I give authorization to use my name and my pet’s name and information as printed below. Yes NoSignature*