New Client Information Form – Companion Pet Clinic Bend

New Client Form

Thank you for giving us the opportunity to care for your pet(s). To insure the best care possible, please take the time to fill out this form in its entirety.

About You
Owner's Name*
First Last
Address*
Street Address City State ZIP Code
Phone*
Email

We agree to keep all personal information confidential. We will never share or sell your information.
Cell Phone (If different from home phone)
Co-Owner/Emergency Contact*
First Last
Emergency Contact Phone*
Owner's Employer*
Owner's Work Phone
Co-Owner's Employer*
Co-Owner's Work Phone
How Did You Learn About Our Clinic
If Recommended, by whom?
About Your Special Companion
Pet's Name*
Type of Animal*
Breed
Color
Birthday
MM slash DD slash YYYY
Sex*
- Check this box if you DO NOT want your pet's picture or name to appear on our website, Facebook, or any promotional materials.
Name of Previous Vet Clinic
Phone
Do we have permission to contact them for health records?
Medical and Vaccine History
Please give a complete description and dates
We accept cash, check, debit, Visa, MasterCard, American Express, Discover, and Care Credit. In case of extensive medical services a deposit may be required. We will gladly prepare an estimate for services upon request. There will be a $25 charge for all returned checks. By sending this form, I hereby authorize the veterinarian to examine, prescribe medication for, or treat my pet and I assume full responsibility for all charges incurred in doing so.

New Client Form

About You

About Your Special Companion