<p>NEW CLIENT FORM Thank you for giving us the opportunity to care for your pet(s). So that we may become better acquainted, please complete the following:</p><p>CLIENT INFORMATION Name ______Spouse/Co-Owner’s Name Address ______City ______State ______Zip Phone (___) ______Spouse/Co-Owner’s Phone ( ___) ______Best time to call ______Place Of Employment ______Work phone (___) ______E-Mail Address ______@ ______Date of birth ______Preferred method of contact: Phone / Text / Email Preferred method of appt or vaccine reminders: Phone / Text / Email How did you become aware of our clinic? Drove by__, Yellow Pages (YP.com)__, Website__, Yelp__, Google__, I am a Previous Client__, Friend __, CHC__, Chino Connects__, Facebook Ad__, Our Facebook Page__, West Coast Magazine__, Chino Champion Newspaper__, Local Event (which one?)______, Other______, Personal Recommendation (Whom may we thank?) </p><p>PET # 1 PET # 2 PET # 3 NAME BREED DATE OF BIRTH COLOR SEX; SPAYED OR NEUTERED? YOUR DOG’S VACCINATION HISTORY: RABIES DAP, DAPL BORDETELLA OTHER DEWORMING YOUR CAT’S VACCINATION HISTORY: RABIES FVRCP LEUKEMIA OTHER DEWORMING Any allergies to vaccinations or medications? Are your pet(s) on any special diets or medications? ALL FEES ARE EXPECTED TO BE PAID IN FULL UPON COMPLETION OF THE VISIT/HOSPITAL STAY. A 75% DEPOSIT IS REQUIRED ON ALL ANIMALS ADMITTED TO THE HOSPITAL. Please indicate choice of payment. € Cash €Debit €Visa €MasterCard €Discover €Amex €Care Credit In the event any balance due hereunder is not paid as agreed or refund is requested by credit card company, the undersigned jointly and severally agrees to pay all costs including said unpaid balance, attorney fees, billing fees, collection fees, and finance charges. Owner Signature ______Date ______</p>