New Client Form| Countryside Veterinary Medical Group

Co-Owner Name (first & last):

Co-Owner Phone Number:

For check-writing purposes please enter your Driver's License ID number

For check-writing purposes please enter your Date of Birth

How did you hear about us?

Internet Search

Drive By

Client Referral

Other

If you were referred by a client, what is their name?

I understand that my pet’s picture may be used on social media sites.

YES, you can use my pet's photo on social media.

NO, do not use my pet's photo on social media.

Authorization

I authorize the veterinarian/medical staff to examine, prescribe for, or treat my pet. I understand that the estimated fee is based on treatments deemed necessary at the time of admission. I am aware that initial estimate may change due to the status of my pet. I assume responsibility for all charges incurred at the time services are rendered an that I can pay by cash, check, Visa, MasterCard, American Express, Discover, Care Credit or Citi Health Card.*

I agree

Pet's Name*

Age / DOB*

Sex*

Female Intact

Female Spayed

Male Intact

Male Neutered

Species*

Breed

Color

Reason for your pet's visit:*

Does your pet have any allergies, special medications, or health problems we should know about?*

What type of food does your pet eat?

Treats?

Dogs:

DHLPP (Distemper combo)
Rabies
Kennel Cough
Lyme
Fecal
Heartworm Test

Is your dog on Heartworm preventative?

Yes

No

Cats

FVRCP (Distemper combo)
Rabies
Feline Leukemia

New Client Form

Co-Owner Name (first & last):

Co-Owner Phone Number:

For check-writing purposes please enter your Driver's License ID number

For check-writing purposes please enter your Date of Birth

How did you hear about us?

If you were referred by a client, what is their name?

I understand that my pet’s picture may be used on social media sites.

Patient Information:

Pet's Name*

Age / DOB*

Sex*

Species*

Breed

Color

Reason for your pet's visit:*

Does your pet have any allergies, special medications, or health problems we should know about?*

What type of food does your pet eat?

Treats?

Dates of Last Vaccinations/Tests:

Dogs:

Is your dog on Heartworm preventative?

Cats

Where were the most recent vaccinations given?

Previous Veterinarian and Phone Number