New Client Form - English – Los Angeles Veterinary Center

Primary Owner *

First

Last

Date of Birth *

Secondary Owner

First

Last

Date of Birth

Address

Address Line 1

Address Line 2

City

State

Zip Code

Preferred Contact Phone # *

Phone Type *

Home
Work
Cell

Alternate Contact Phone #

Phone Type

Home
Work
Cell

E-mail *

Can we send you text message notifications?

Yes, please!
No thank you.

If yes, Phone #:

Preferred Method of Communication: *

Call
Text
Email
Postal Mail

How did you learn about us? *

If friend/relative: whom may we thank?

Pet's Name *

Dog or Cat? *

Dog
Cat

Breed: *

Age/D.O.B: *

Color: *

Sex

Male
Female

Spayed/Neutered?

Yes
No

Microchip #

Previous Doctor/Clinic Name:

May we request records?

Yes
No

Vaccination History:

Can we use photos of your pet on Social Media?

Yes
No

I, the undersigned, owner or authorized agent of the above patient, hereby authorize the admitting veterinarian (and his designated associates/assistants) to administer such treatment as needed for the benefit of this patient. I also consent to the administration of such anesthetics as needed. I further understand that no guarantee of successful treatment is made. I also assume financial responsibility for all charges incurred to this patient, and agree to pay all such charges at the time the patient is released. PAYMENT IS DUE AT TIME OF SERVICE. *

I have read and understand.

Digital Signature of Primary Owner/Agent: *

Today's Date *

Digital Signature of Secondary Owner/Agent:

Today's Date