New Clients | Georgetown Veterinar

New Client Form

Please tell us about you and your pet.

Pet Owner's first name

Pet Owner's last name

Address

Address line 2

Primary phone

Work phone number

Co Owner name

Co Owner phone number

How did you hear about our practice?

Pet name

Dog/Cat/Other (please indicate)

Male or Female

Age

Birthdate

Breed

Color

Spayed/Neutered?

At what age spayed/neutered?

Where was your pet obtained?

At what age was pet obtained

Describe your pet's diet

List current medications. Write N/A if none.

Reason for visit

AUTHORIZATION STATEMENT: 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 the animal. I understand that there is a $50 cancellation fee for each appointment cancelled within 24 hours of the scheduled appointment time, and a $250 charge for any surgery cancelled within 48 hours of the scheduled surgery time or missed completely. I also understand that ALL PROFESSIONAL FEES ARE DUE AT THE TIME OF SERVICE ARE RENDERED.

YOU MUST SIGN BELOW TO ACKNOWLEDGE YOU HAVE READ AND ACCEPT THIS AUTHORIZATION STATEMENT.

Signature

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