Receptionist FISCHER VETERINARY CLINIC, P.A. Date: __

Receptionist ____ FISCHER VETERINARY CLINIC, P.A. Date: ______NEW CLIENT FORM

OWNER INFORMATION

Name: ______Spouse/Co-Owner’s Name: ______Street address: ______City: ______State: _____ Zip: ______Email address: ______Cell Phone: ______Place of employment: ______Work Phone: ______Emergency Phone:______

If a friend told you about us, whom may we thank? ______If referred to a specific doctor, please circle: Dr. Almany Dr. McGuire Dr. Fischer Dr. Aven Dr. Word

PAYMENT FOR SERVICES Payment is expected today when services are rendered. Please indicate how you will be paying for today’s visit: Cash Check Visa M/C Discover Other Driver’s license #: (if paying by check) ______

PET INFORMATION Pet #1 Pet # 2 Pet #3 Pet’s name Species: Dog/Cat Dog/Cat Dog/Cat Breed Color Birth date (or estimated age) Gender (Sex) MALE FEMALE MALE MALE FEMALE FEMALE Has he/she been neutered? YES NO YES NO YES NO Current on vaccinations? YES NO YES NO YES NO Name of current medication(s)? Drug/vaccine reactions YES NO YES NO YES NO Prior illness or surgery? Is your pet micro-chipped? YES NO YES NO YES NO What do you feed your pet? On heartworm prevention? YES NO YES NO YES NO

REASON for your pet’s visit today? 1. Annual check-up/vaccinations______OR 2. Medical concern______Picture Release A picture of your pet will be taken to be included in the pet’s record. Additionally, we may also like to use your pet’s picture for social media or educational purposes. Please indicate below if you give us permission for such purposes beyond the clinic record. I give permission for my pet to have its picture taken and used anonymously by Fischer Vet Clinic for social media or educational purposes. Please initial your choice: YES _____ NO _____

Thank you again for trusting our entire health care team with your pet. If there is anything else we can help you with, please let us know. Be sure and visit us at www.fischerveterinaryclinic.com