"*" indicates required fields

Name

First Last

Spouse's Name

Address

Street Address City State / Province / Region ZIP / Postal Code

Home Phone Number

Cell Phone

Spouse's Number

Emergency Contact

Number

Place of Employment

Work Number

May we contact you at work?

Yes

How did you learn about Pampered Pets?

Pet Information

Pet 1

Name

Sex

Spayed/Neutered

Breed

Color

Birthday

Has your pet had any illnesses, surgeries, or injuries that we should be aware of?

Previous Veterinarian

Pet 2

Name

Sex

Spayed/Neutered

Breed

Color

Birthday

Has your pet had any illnesses, surgeries, or injuries that we should be aware of?

Previous Veterinarian

Pet 3

Name

Sex

Spayed/Neutered

Breed

Color

Birthday

Has your pet had any illnesses, surgeries, or injuries that we should be aware of?

Previous Veterinarian

Authorization

I understand that Pampered Pets Veterinary Clinic and Spa is not responsible for any accidental illness or injury incurred by my pet(s) while visiting Pampered Pets Veterinary Clinic and Spa. I also understand that for any other individual to bring my pet in for treatment I must give authorization. Parties must be over the age of 18.

Name of authorized individuals over 18 that may bring i my pets for Treatment:

I authorize Pampered Pets Veterinary Clinic and Spa to use photos of my pet(s)for their website or social media outlets:*

Yes

Please Initial*

Signature*

Date*

Payment due at time of service. No exceptions.

New Client Information Form

Pet Information

Authorization

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