New Client Form

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New Client Form

Please fill out this form as completely and accurately as possible so we can get to know you and your pet(s) before your visit.

CLIENT INFORMATION

Date

Name *

Contact Number

Secondary Contact

Secondary Number

Email *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

All fees are due at the time services are rendered. We accept cash, MasterCard, Visa, and Discover.

Surgery Deposit Policy. If you plan to schedule surgery, we require a non-refundable deposit of $75 to reserve your surgery date. This will be applied to the balance of the surgery. If you miss your appointment the deposit is subject to forfeit at Canyon Lakes Veterinary Clinic’s discretion.

I agree *

I, the undersigned, am the owner or authorized agent of the owner of all pets listed below, now or in the future under my account, and do hereby authorize Canyon Lakes Veterinary Clinic, their agents, and assigns, to perform such examinations, diagnostic tests, and treatments as they deem necessary. I further agree to be financially responsible for all cost for such services, procedures, and treatments. I understand that full payment is due at the time services are rendered. I understand that abandonment of animals does not relieve me of this financial obligation. If any balance remains unpaid on my account, I agree to pay the cost of collections, legal action, and any other reasonable costs incurred in collecting my debt.

Signature

Clear Signature

Date

PATIENT INFORMATION

Pet's Name *

Species (dog, cat, etc.) *

Breed *

Age *

Color *

Sex *

Male
Female

Does your pet have a microchip identification? *

MEDICAL HISTORY

Has your pet ever had the following?

Spayed/Neutered

Major Illness

Seizures/Episodes

Ever Tested (+) for Heartworms?

Taking Any Medications?

History of adverse reactions to medications or vaccines

New Client Form

New Client Form

CLIENT INFORMATION

All fees are due at the time services are rendered. We accept cash, MasterCard, Visa, and Discover.

PATIENT INFORMATION

MEDICAL HISTORY

Has your pet ever had the following?

MEDICAL HISTORY

Has your pet ever had the following?

MEDICAL HISTORY

Has your pet ever had the following?

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Location

Contact Information

Hours