New Client Form I Salazar Veterinary Hospital

Pet Owner

Please fill in the details below so that we can get in contact with you.

First Name

Last Name

Address

Phone Number

Mobile Phone Number

Email

Step 1

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Pet's Information

First Name

Last Name

Species

Breed

Gender

Neutered / Spay

Date of Birth or approximate age

Pet Insurance Information

Step 2

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Pet's Information

Food Type

Pet Food Brand

Amount

Has your pet visited the vet within the past 3 years?

If Yes, At which veterinary office can we find your pet’s medical records?

Step 3

3 / 8

Routine Health Care Questions

General

Step 4

4 / 8

Is Your Pet on Any Current medications?

Does your pet have any chronic medical problems?

Has your pet had any illnesses, injuries or recent medical problems?

Step 5

5 / 8

Routine Health Care Concerns

Have you noticed any

Step 6

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Have you noticed any changes in your pets?

Reason for today's visit

Step 7

7 / 8

How did you hear about us?

Authorization/Payment Policy

Payment is due when services are completed or when patient is released. It is our policy to provide you with a written estimate of fees for any in-hospital treatment, surgery, or emergency care. If you have any questions regarding fees, we will be happy to discuss them with you at any time. We accept Visa, MasterCard, Discover, American Express, and Cash payments. We will also accept Care Credit and Scratchpay for qualified applicants.

Confirmation

8 / 8

What's your best contact email?

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