New Patient/Client Information Form

ALLIANCE ANIMAL CLINIC NEW PATIENT/CLIENT INFORMATION - please type in the information (or print and fill in) and bring the completed form to the clinic the day of your first visit- set printer to "size to fit" your paper
Appointment Date
Owner's Name		Spouse/Other
Children	*first names & ages
Street Address		City, State, Zip
Phone Number		Best time to call?
Email Address		Receive email updates?
Employer		Work Number
Emergency Contact		Emergency Number
Preferred Payment
How did you hear about our hospital? Is there someone we can thank?
Would you like to be added to our postal mailing list?

To prevent the spread of infectious diseases and parasites, we recommend that hospitalized and boarded animals are current on all vaccinations and free of internal and external parasites. By signing below, I authorize the doctor to provide vaccinations and parasite control as needed for my pet.
Sign Printed Copy

YOUR PET(S) MEDICAL HISTORY Click HERE for additional forms if you have more than 1 pet you wish to add to your account at this time.
Pet # 1
Name		Species (dog, cat, etc.)
Breed		Description (color/markings)
Date of Birth		Age (years, months, weeks)
Sex		Diet (type & amount of food)
Grooming Products		Hours Outside Each Day
Vitamins		Where did you get your pet?
How old was your pet when you first got it?
VACCINATIONS:	In the spaces provided, list the last known dates of vaccinations, if applicable.
CANINE	Distemper	FELINE	Distemper
	Corona		FeLV
	Parvovirus		Rabies
	Bordetella
	Rabies	Adverse reactions to vaccinations?
	Lyme Disease
	Heartworm Test
Heartworm Prevention
Has your pet had a FECAL EXAM?		Results
Has your pet had any DENTISTRY performed?		Type
Prior Illnesses
Prior Surgery


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