New Client Card – Blackfalds Veterinary Hospital in Blackfalds, Alberta

Date

MM

DD

YYYY

Owner

First Last

Spouse

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone

Cell Phone

Spouse Phone

Emergency Contact

First Last

Phone

Owner's Place of Employment

Phone

Spouse's Place of Employment

Phone

Email

Previous Veterinary Clinic

Comments

Pet Health History

Name of Pet

Pet Species

Dog
Cat

Other

Breed

Colour

Date of Birth / Age

Male

Neutered
Not Neutered

Female

Spayed
Not Spayed

When was your pet last vaccinated?

Current Medications

Curent Food Brand

Any Ongoing Medical Concerns

Authorization

PROFESSIONAL FEES ARE TO BE PAID AT THE TIME SERVICES ARE PERFORMED.In admitting my pet(s) for diagnostic, treatment, or surgery, I authorize the veterinariansof BlackfaldsVeterinary Hospital, and their support staff, toperform such treatment and/or perform such diagnostic or surgical procedures as deemed necessary. It is understood that an estimate of charges will be given for services at the client’s request. No guarantee or assurance can be made as to the results that may be obtained. I understand that a deposit of 50% may be required before services are performed and I assume full financial responsibility for all charges incurred by my pet. I realize that these charges may exceed a given estimate if complications arise. I understand that I will be contacted prior to treatment, if possible, should complications occur.

Signature of owner*

Date*

MM

DD

YYYY