<p> NEW CLIENT INFORMATION-CLEARVIEW ANIMAL HOSPITAL, PC</p><p>Date______</p><p>Client Full Name: ______Last First Middle</p><p>Spouse Full Name: ______Last First Middle</p><p>Address: ______City:______Zip:______</p><p>Home Phone: ______Cell Phone: ______</p><p>Employer: ______Work Phone: ______</p><p>*If self-employed, write in business name ______</p><p>Spouse’s Employer: ______Work Phone: ______</p><p>*If self-employed, write in business name ______</p><p>Emergency contacts and alternate numbers to reach you: ______</p><p>______</p><p>Referred by: ______</p><p>Method of Payment: Cash Check Credit/Debit Card </p><p>Driver’s license # ______exp. ______</p><p>***Please note: You are responsible for payment at time of service. ***</p><p>PATIENT INFORMATION:</p><p>Name: ______</p><p>Dog Cat Other ______</p><p>Breed: ______Color: ______Date of Birth ______</p><p>Gender: Male Female Altered? Yes No </p><p>Additional Animals: ______Repeat the same information. Use the back if necessary.</p>