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