New Client Form

Welcome to Oliver Animal Hospital

Owner Name:_______________________________________________________________________
                          First                                                                 Last

Address:_______________________________City:_________________ State:_____ Zip: __________

*****Please indicate which phone number is best to contact you*****
Home Phone:________________________________Work Phone:______________________________

Cell Phone:__________________________________Email:___________________________________

Spouse:____________________________________

Spouse’s Cell Phone:________________________

Alternate Contact Person:________________________________________________
                                             First                                                           Last
Alternate Contact Phone:__________________________________

Whom may we thank for referring you or how did you hear about us?

_____________________________________________________

Employer:_____________________________________________

Patient Information

Name:_____________________________________

Sex: Male/Neutered Male                Female/Spayed Female

Birth Date:______________ or Age:________             Species:  Canine   Feline   Other:___________

INDOOR                        OUTDOOR                    INDOOR/OUTDOOR

Breed:____________________________________________  

Color:____________________________________________

Markings:_________________________________________

Microchip Number:__________________________________

Do you have pet medical insurance?___________ Company_____________________  

Food or Drug Allergies?___________________________________
Current Medications:____________________________________________________
*Due to a Texas Privacy Act we may need consent from owner to obtain previous medical history/records.*
Previous Veterinary Hospital: _____________________________________________

We do not accept personal checks.              
All professional medical services must be paid in full at the time they are rendered.
       

We accept credit cards, debit cards, care credit, and cash.
As a pet guardian, you will be held liable for the financial responsibility of services that are performed for each pet.  Unpaid balances will be recovered as deemed appropriate by Oliver Animal Hospital management and may incur a $30.00 administration fee.  A 1.5% monthly interest fee will be charged on all unpaid balances. I understand and abide by the above statements.

Signature:_______________________________________________ Date:________________________