New Client Registration Form - Companion Animal Clinic

Welcome to Companion Animal Clinic! Please share more information about you and your pet below.

Please complete this form as fully as possible prior to your first appointment which will help expedite the registration process and give us valuable insight in providing optimal care for your pet(s). The required sections have a red * asterisk.

First Name

Last Name

Email Address

Confirm Email

Daytime Phone

Home Phone

Employer

Work Phone (If different than Daytime Phone)

Secondary Contact

First Name

Last Name

Daytime Phone

Mailing Address

Preferred Contact Method

Email Regular Mail/Postage

Pet Name

Date of Birth (if known)

Species

Sex

Breed

Color, Markings, and Identification (microchipping, etc)

Specify any past health medical conditions, concerns about your pet's current health, and any known allergies or drug reactions.

List any preventives, medications, or supplements you provide your pet

Please describe your pet's diet to include brand of food and the quantity and frequency of feeding.

Has your pet been treated for illness in the past year?

Yes No

Previous Veterinarian(s) where past records could be obtained:

Additional Information

Who should we thank for referring you to us?

I assume responsibility for all charges incurred in the care of this animal. I also understand these charges will be paid at the time of service or release and that deposit may be required for surgical treatment.

I agree to the Terms & Conditions

New Client Offer

$75 Off Your Pet’s First Appointment

New clients save $75 on their first exam.

Use code NC75

* Valid for new clients only. Not valid with any other offers. Must mention NC75 at time of booking.