New Client Form Step 1 of 3 33% Owner Name* Co-Owner Name Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code New Clients - please be aware that our schedule often has very specific timing for open appointments. If you live more than 20 miles from the clinic, or are only typically available in the evenings and weekend, we may not always be able to accomodate your preferred timing. Also - please plan accordingly for heavy traffic flow around Frederick. Email Address* Home Number Work Number Cell Number* Would you like to receive appointment reminders by text message?* Yes No *Note, appointment reminders will also be sent by email, along with patient reminders and messages from the Doctor. If you do not use email, please let us know. Co-Owner Work Number Co-Owner Cell Number Name of Previous Clinic Phone Military or First Responder Yes No If yes, please bring appropriate ID to your first appointment to receive the discount. Recommended by Whom? If referred by a current client, they will receive a $15 credit on their account. First PetSelect One:* Dog Cat Pet InformationNameBreedMicrochip#Date of BirthColorSexSpayed or NeuteredTemperamentPet Insurance CompanyDate of VaccinationsRabiesDA2PParvoCoronaBordetella Date of VaccinationsRabiesFELVENT-FVRCPFIP Second PetSelect One: Dog Cat Pet InformationNameBreedMicrochip#Date of BirthColorSexSpayed or NeuteredTemperamentPet Insurance CompanyDate of VaccinationsRabiesDA2PParvoCoronaBordatella Date of VaccinationsRabiesFELVENT-FVRCPFIP Third PetSelect One: Dog Cat Pet InformationNameBreedMicrochip#Date of BirthColorSexSpayed or NeuteredTemperamentHas Pet InsuranceDate of VaccinationsRabiesDA2PParvoCoronaBordatella Date of VaccinationsRabiesFELVENT-FVRCPFIP Audio Recording Consent* I agree to the recording policy.Our veterinary services utilize ScribbleVet, a tool from Kairo Care, Inc., which records your pet's appointments for improved clinical documentation. By submitting this new client form, you agree to: 1. Appointment Recording: You agree that your vet appointments may be recorded. If you don’t want to be recorded, let us know. 2. Usage Rights: You grant us permission to share these recordings, and any other materials you choose to provide, for the purpose of improved clinicaldocumentation. 3. Age Confirmation & Understanding: You affirm that you are at least eighteen years old, and that you understand and accept the terms in this agreement.We are committed to providing the best care for your pet in a manner comfortable for both of you.I/we hereby authorize the veterinarians to examine, prescribe for, or treat my pets (s). I/we assume full responsibility for all charges incurred in the care of this/these animal(s). I/we also understand that these charges will be paid in full at the time of release and that a deposit may be required for certain surgical treatments or other procedures. Type Signature PhoneThis field is for validation purposes and should be left unchanged.
