New Client Form - Center Line Veterinary Hospital

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 Type	Phone Number

Cell #
Phone Type	Phone Number

Work #
Phone Type	Phone Number

Spouse #
Phone Type	Phone Number

Spouse Cell #
Phone Type	Phone Number

Spouse Work #
Phone Type	Phone Number

Emergency Contact Name and Phone #

How did you learn of our clinic? :

If Referred - Name of person who referred us!

Number of dogs in your home :

Number of cats :

If no cats or dogs, how many other pets?

Name of Pet

Type of Pet :

Breed

Color

Birthdate / Age

Male - Neutered? :

Female -Spayed? :

Up to date on vaccines? :

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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Center Line

Center Line Veterinary Hospital

New Client Form Form

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