New Client Form

Please fill out this form as completely and accurately as possible so we can get to know you and your pet(s) before your visit.

You may use the PDF version by clicking the DOWNLOAD FORM button and completing the printed form by hand. Please bring the completed PDF form with you for your pet’s first appointment.

DOWNLOAD FORM

Date *

Referred By *

Appointment Date *

Appointment Time *

Name *

First

Last

Email *

Home Phone *

Work/Cell Phone *

I consent to receive SMS text messages from Flanders Veterinary Clinic. Msg & data rates may apply. Reply STOP to opt-out. *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Pet's Name *

Sex *

Species (dog, cat, etc.) *

Breed *

Age/Date of Birth *

Color *

Is your pet currently on ant medications? *

Special Consideration (pre-existing conditions, allergies, treatments) *

Is your pet currently on any medications? *

Previous Veterinarian *

Previous Veterinarian Address *

Address Line 1

Address Line 2

City

State

Zip Code

Previous Veterinarian Phone *

Previous Veterinarian Fax *

May we request your pet's medical/vaccination history for our records? *

How will you be paying today? *

Cash
Check
Credit Card

**There will be an APR of 18% and a $2.00 billing charge to all non-zero balances after an initial 30 day grace period**

**Please note that any information reported on this form will remain in our files and is strictly for the use of Flanders Veterinary Clinic**

Signature *

Clear Signature

Date *

Message

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