New Pet Form (printable)
Westown Veterinary Clinic New Patient Form
Please Print Legibly
Pet Owner’s Name(s)__________________________________________________________________
Address__________________________________ City_______________ State_____ Zip_______
Home Phone_____________________ Work #___________________ Alt#_______________________
Pet’s Name___________________ Dog____ Cat____ Breed__________________ Birth Date_______
Color(s)_________________________ Sex: Female Male Spayed/Neutered: YES/NO
Vaccination History (Indicate the date(month/year) your pet received the following vaccinations)
Dog: Cat:
Rabies (indicated 1, 2, or 3 yr) ________ Rabies (indicate 1, 2, or 3yr)_________
Lyme________ Leukemia test & result (FELV)________
Corona virus ________ Leukemia vaccine (FELV)____________
Distemper/Parvo/Lepto________ Distemper________________________
Bordetella________
Nutrition
Dry brand_______________________ Canned Brand_____________________ Table scraps ? YES/NO
Heartworm Preventative
Is your pet currently taking a heartworm preventative YES/NO
If yes, what brand?________________________ Monthly______ Seasonally_______
Flea Preventative
Is your pet currently using a flea preventative? YES/NO
If yes, what brand?________________________ Monthly _______ Seasonally______
Medical Conditions (Allergies, drug reactions, heart conditions, etc.)
________________________________________________________________________________________________________________________________________________________________________________________
Medical Records
_____________________________________________________________________________________ Name of the hospital(s) where they can be obtained and/or phone number
Signature to obtain record _________________________________
FULL PAYMENT IS DUE AT THE TIME OF SERVICE: CASH OR CREDIT ONLY
Owner’s signature___________________________________________________ Date___________
Email Address: __________________________________________