COMPANION ANIMAL CLINIC

New Client and Patient Information

Thank you for giving us the opportunity to care for your pet. Please help us better meet your needs by taking a few moments to fill out this information sheet.

Your name: _____________________________          Cell phone: ____________________

Spouse/Partner’s Name: ___________________           Cell phone: ____________________

Home Address: __________________________           City: ____________ State: ___ Zip: _______

Your work phone: ________________ Spouse/Partner’s work phone: ___________

Home phone: ___________________     

Please tell us about your animals

PROFESSIONAL FEES ARE DUE AT THE TIME SERVICES ARE RENDERED

We will gladly prepare a printed estimate if you desire. Please ask the veterinarian.

If you wish to pay by check, please complete the following information, otherwise we must request cash or credit card as payment.

For check writing privilege, please enter driver’s license number: __________________

For your convenience, we accept Visa, MasterCard, American Express and Discover.

How did you hear about Companion?

(  )Individual (Someone we may thank?) _____________________________________

(  )Yellow pages  (  )Internet  (  )Clinic sign/drive by  (  )Previous Client  (  )Other: ________

I understand I am responsible for the payment of fees for services rendered to my animal by the

attending veterinarian and assume full financial responsibility.

Signature of owner: __________________________    Date: ____________

Staff member verifying information: ___________