New Client Information Form (English)

Welcome to Horizon Veterinary Specialists.
Thank you for giving us the opportunity to care for your pet. To ensure the best possible care, please take the time to complete this form in its entirety.
1. Owner's Name:*
First Last
Phone #:*
Secondary Contact Name:*
First Last
Secondary Contact Phone #:*
Address:*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Email:*
Driver's License #:*
Expiration Date:*
MM slash DD slash YYYY
Owner's Date of Birth:*
MM slash DD slash YYYY
Patient's Information:
2. Name of patient:*
Pet's Name
Patient's Date of Birth:*
MM slash DD slash YYYY
Sex:*
Species:*
Breed:*
Color:*
Allergies (If none, put "None."):*
Date of last Rabies Vaccine (If you don't know, skip.):
MM slash DD slash YYYY
Previous Medical Conditions (If none, put "None."):*
Second Patient (if not applicable, skip this section):
3. Name of second patient (If not applicable, skip to #4.):
Pet's Name
Date of Birth:
MM slash DD slash YYYY
Sex:
Species:
Breed:
Color:
Allergies (If none, put "None."):
Date of last Rabies Vaccine (If you don't know, skip.):
MM slash DD slash YYYY
Previous Medical Conditions (If none, put "None."):
Referral Information:
4. Referred by:*
Referral by Client - Please list their name:
Referral by Veterinarian - Please list their name:
Phone:

Referral Veterinarian's phone number.
Please list your Primary Veterinarian:
Phone:

Primary Veterinarian's phone number.
5. Consent to share medical information:*
Authorize to share medical information.
I consent to have Horizon Veterinary Specialists share medical information with other clinics, boarding, grooming, and pet insurance companies.
6. Authorization of treatment:*
I authorize treatment of my pet(s) per the agreement below.
I authorize the staff of Horizon Veterinary Specialists to render any treatment that is deemed necessary to my pet(s) health while in custody of the hospital. I understand that in the event of any unusual or emergency circumstances, the staff will make every attempt to contact me or my designated representative before, if time permits, proceeding with treatment. I understand that I will be financially responsible for all emergency procedures including the Estimate of Charges provided to me in person, email, or over the phone. I understand that these fees are to be paid at the time of services rendered and a deposit is required on all pes staying at the hospital.
Signature*

This Acknowledgement and Certification of Understanding is to let you know that by submitting an electronic signature, you are providing an electronic mark, that is held to the same standard as a legally binding equivalent of a handwritten signature provided by you for all documents within this task.
Date*
MM slash DD slash YYYY

New Client Information Form (English)

Welcome to Horizon Veterinary Specialists.

Patient's Information:

Second Patient (if not applicable, skip this section):

Referral Information: