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 message Email Post Card
How did you first learn of our hospital? We would like to thank any individual who referred you.
 Hospital Sign Direct Mail Radio Add Yellow Pages Ad Newspaper Website/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