New Client Form - Veterinary Medical Center of The Woodlands

Client Information

Date*

Owner's Name*

Home Address*

Primary Phone Number*

Alternative Phone Number

Email*

Enter Email Confirm Email

Place of Employment*

Work Phone Number

Spouse/Partner/Co-Owner's Name

Spouse/Partner/Co-Owner's Phone Number

Emergency Contact Name

Emergency Contact Phone Number

Do you have pet insurance? If yes, what is the name of the pet insurance?

How did you hear about us?*

Please Specify

Promotion Code

Pet Information

Pet Name*

Species*

Dog
Cat
Exotic Pet

Breed*

Color/Markings*

Birthday/Age*

Sex*

Male
Female

Is your pet spayed/neutered?*

Yes
No
I don’t know

Dog Vaccines

For dogs, please confirm which vaccines are current for your pet.

Rabies Vaccine

DHPP Vaccine (Distemper)

Bordetella Vaccine

Canine Influenza H3N2 & H3N8 Vaccine

Leptospirosis Vaccine

Cat Vaccines

For cats, please confirm which vaccines are current for your pet.

Rabies Vaccine

FVRCP Vaccine

Feline Leukemia Vaccine

Pet Medical History

Any known allergies?

Any chronic health problems?

Is your pet microchipped?*

Should your pet be muzzled?*

Has your pet been seen by a veterinarian previously? If yes, please fill in the name of the clinic. If no, please type "No."*

Reason for visit or any other questions/comments.

Authorization

We may need to contact you about your pet’s health, please consent by selecting the best method(s) of communication:**

Home Address (Mail)
Primary Phone Number
Work Phone Number
Text Message

Permission to share your records with Other Hospitals/Emergency/Specialty?*

Permission to share your records with Groomers/Daycare?*

Permission to share your records with Pet Insurance?*

Media Consent*

I grant to Veterinary Medical Center of the Woodlands, its representatives and employees the right to take photographs of me and/or my pet, and to copyright, use and publish the same in print and/or electronically. I agree that Veterinary Medical Center of the Woodlands may use such photographs of me and/or my pet with or without my name and for any lawful purpose, including but not limited to publicity, illustration, advertising, and web content.

Authorization*

I, the undersigned, do hereby certify that I am the owner, or assuming responsibility, financial or otherwise, for the animal being presented to Veterinary Medical Center of the Woodlands for treatment and care. I hereby consent and authorize Veterinary Medical Center of the Woodlands to receive, prescribe for or treat, as indicated, this animal presented. It is thoroughly understood that I assume all risks. I agree, if appropriate, to pick up this animal at the designated date and time agreed to by myself and Veterinary Medical Center of the Woodlands. If the event that the animal is not picked up, there will be a notice with a 10-day notice to come claim said animal or it will be considered abandoned. The animal will be handled in the manner that is considered to be most appropriate for the pet and the hospital. It is understood that I am not released from costs associated with the care of the pet.

Owner/Responsible Party*

Date*

Name

This field is for validation purposes and should be left unchanged.