Patient Information Form — Alternative Veterinary Therapies

New Client Info

Welcome to Alternative Veterinary Therapies. Thank you for giving us the opportunity to be part of your pet’s health care team. Please take a moment to fill out this information form. This will place your pet on our New Patient list and we will contact you to schedule an initial consultation and evaluation.

Primary Owner/Agent Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home Phone

(###)

###

####

Cell Phone

(###)

###

####

Work Phone

(###)

###

####

Spouse/Co-owner Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home Phone

(###)

###

####

Cell Phone

(###)

###

####

Work Phone

(###)

###

####

How did you first learn of our clinic?

We like to brag about our patient's accomplishments. Will you allow us to share photos, video clips, or brief anecdotes of you and your pet(s) on our website, Facebook page and other social media?

Signature

Date

YYYY

By checking this box and typing my full name in the signature box above, I acknowledge that I am electronically signing this form.

I agree

Pet's Name

Primary Veterinary Clinic

Primary Veterinarian

Species

Breed

Color

Pet's Date of Birth

YYYY

Sex

Neutered/spayed

Yes

Microchip or Tattoo (specific number if available)

Current Diet

Current concerns or problems? What leads you to seek our care?

Major past illnesses, injuries, other issues?

Current medications and supplements (list)