Center Line Veterinary Hospital

26242 Van Dyke Avenue
Center Line, MI 48015

(586)758-5620

www.centerlinevet.com

New Client Form Form

Date :
E-Mail Address :
Owner
First Name
Last Name
Address
Street Address
City
,
State / Province
Zip / Postal Code
Home #
Phone TypePhone Number
Cell #
Phone TypePhone Number
Work #
Phone TypePhone Number
Spouse #
Phone TypePhone Number
Spouse Cell #
Phone TypePhone Number
Spouse Work #
Phone TypePhone Number
Emergency Contact Name and Phone #

How did you learn of our clinic?

Sign
Internet
Referred


If Referred - Name of person who referred us!

Number of dogs in your home

1
2
3
4


Number of cats

1
2
3
4


If no cats or dogs, how many other pets?

Name of Pet

Type of Pet

Dog
Cat
Other


Breed

Color

Birthdate / Age

Male - Neutered?

Neutered
Not Neutered


Female -Spayed?

Spayed
Not Spayed


Up to date on vaccines?

Yes see below
Not up to date


Vaccination Location / Veterinary Practice

Medical Alerts

Microchip

Reason for visit

Please check any problems that you have noticed about your pet
Selection
Behavior
Breathing Problems
Coughing / Gagging
Diabetes
Diarrhea
Eyes
Ears
Lack of appetite
Limping
Loss of Balance
Scooting
Scratching
Lethargy
Seizures
Shaking Head
Sneezing
Increase thirst / urination
Vomiting
Weakness
Other (See below)
Other Issue

Pet's current medications and diet

By checking this box I hearby authorize the veterinarian to examine, prescribe for or treat the above described pet. I assume responsibility for all charges incurred in the care of this animal.
By checking this box I also understand that these charges will be paid at the time of services rendered abd a deposit may be required.

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