New Client Register

    PRIMARY OWNER *

    First Name*

    Last Name*

    Date of Birth


    SECONDARY OWNER

    First Name

    Last Name

    Date of Birth



    Address

    City

    State

    Zip




    Preferred Contact Phone #*

    Phone Type

    Alternate Contact Phone #

    Phone Type

    Email

    Can we send you text message notifications ?

    Preferred Method of Communication
    CallTextEmailPostmail

    How did you learn about us ?
    Walk/drive byHere PreviouslyInternetYelpGoogleFriend Relative

    If friend/relative: Whom may we thank

    Appointment Date and time (If you don't have an appointment, please call us at 323-685-7131 to schedule today!)

    Date

    Time

     

    Pet name*

    Dog or cat

    Breed*

    Age/Date of birth*

    Color*

    Sex

    Spayed / Neutered

    Microchip #

    Previous Doctor / Clinic Name

    May we request records?

    Vaccination History

    Upload Attachments (Ex: X-ray Images of Previous Test Reports)

    Additional Attachments

    Can we use photos of your pets on social media?

     

    I, the undersigned, owner, or authorized agent of the above patient hereby authorize the admitting(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 THE TIME OF SERVICE.

    Signature of Preferred Owner*
    Today date*
    Signature of Preferred Owner
    Today date