New Customer Form

New Customer Form

    Magie Veterinary Clinic

    PATIENT/CLIENT INFORMATION 


    Welcome to Magie Veterinary Clinic. Thank you for giving us the opportunity to care for your pet. Please help us meet your needs better by taking a moment to complete both sides of this information sheet.

    Your Name/Title

    Spouse/other

    Address

    City

    Zip

    Home Telephone

    Cell Telephone

    Email Address

    Spouse/Other Email

    Your Employer

    Employer Telephone

    Spouse's Employer

    Employer Telephone

    Your Driver's License Number

    State

    In case of EMERGENCY, please call

    How do you prefer to be notified of reminders?

    Phone messageEmailPost Card

    How did you first learn of our hospital? We would like to thank any individual who referred you.

    Hospital SignDirect MailRadio AddYellow Pages AdNewspaperWebsite/Facebook

    Referred by

    AT YOUR REQUEST WE WILL GLADLY DISCUSS COST OF SERVICES AND/OR PREPARE A WRITTEN ESTIMATE FOR RECOMMENDED PROCEDURES. ALL FEES ARE DUE AT THE TIME SERVICES ARE RENDERED. DEPOSITS MAY BE REQUIRED FOR PETS BEING ADMITTED.

    We accept cash, checks drawn from a local bank, debit cards, VISA, MasterCard, American Express and Discover Card. We charge a $25 fee for returned checks.


    TO PREVENT THE SPREAD OF INFECTIOUS DISEASES AND PARASITES, WE RECOMMEND ANIMALS BE CURRENT ON ALL VACCINES. PETS WITH FLEAS WILL BE TREATED WITH A TOPICAL OR ORAL FLEA MEDICATION ON ADMISSION, AND THE PRESCRIPTION PRICE WILL BE INCLUDED IN THE INVOICE. I AUTHORIZE ADMINISTRATION OF PARASITE CONTROL AS NEEDED FOR MY PET(S).

    Signature

    DATE

    ANIMAL IDENTIFICATION AND MEDICAL INFORMATION

    PET # 1

    PET # 2

    PET # 3

    Name

    Species (cat/dog/horse/etc)

    Breed

    Description/color

    Age

    Date of Birth

    Sex

    Spayed/Neutered?

    Length of Time Owned

    Previous Hospital/Vet

    Microchip #

    Vaccinations

        Parvo/Distemper

        Bordetella

        Rabies

        FVRCP

        FELV

    Any Other Vaccines?

    Kennel

    Current Medications

    Special Diet

    Prior Illness/Accidents

    Prior Surgery/Dentistry


    DETAILS