Client Number:______________
Delavan Lakes Veterinary Clinic S.C.
NEW CLIENT FORM
Thank you for giving us the opportunity to care for your pet(s). To become better acquainted, please complete and share the following
information below.
Client Information
Date_____/_____/_____
Your Name__________________________________________ DOB_____/_____/_____
Spouse’s Name______________________________________ DOB_____/_____/_____
Physical Address________________________________ Mailing Address___________________________________
City___________________________ State_____ Zip Code_________________
Home Phone_(______)_______________________ Cell Phone_(______)______________________
Email_______________________________ (We will only use your email address for vaccine reminders, newsletters, and promotions)
Your Employer__________________________________________________Employer’s Number__(______)__________________
Spouse’s Employer______________________________________________ Employer’s Number__(______)__________________
Driver’s License Number and Exp. Date__________________________________________________________________________
All fees are due at the time of service OR upon release of animal
Please circle choice of payment below:
Cash
Debit
Visa
MasterCard
Discover
American Express
CareCredit
Please circle how you found out about us below:
Drove By
Yellow Pages
Newspaper Ad
Previous Client
Website/Search Engine
Personal Recommendation (Whom may we thank?)__________________________________________________________________
Pet Information #1
Name___________________________ DOB_____/_____/_____ Breed______________________________ Color______________
Male: Neutered ________ Unaltered________
OR
Female: Spayed________ Unaltered________
Please list any of the following information below about your pet:
Previous illnesses or surgeries_________________________________________________________________________________
Allergies to vaccinations or medications_________________________________________________________________________
Special diets or medications___________________________________________________________________________________
Vaccination History (provide the date(s) last given below)
Canine:
Rabies:_____/_____/_____ DHLPP (Distemper):_____/_____/_____ Bordetella:_____/_____/_____ Lymes:_____/_____/_____
Heartworm Test:_____/_____/_____ Other (__________):_____/_____/_____
Feline:
Rabies:_____/_____/_____ FVRCP (Distemper):_____/_____/_____ Leukemia:_____/_____/_____
FELV-FIV Test: _____/_____/_____ Other (__________):_____/_____/_____
(Reverse side for additional pet information)
Pet Information #2
Name___________________________ DOB_____/_____/_____ Breed______________________________ Color______________
Male: Neutered ________ Unaltered________
OR
Female: Spayed________ Unaltered________
Please list any of the following information below about your pet:
Previous illnesses or surgeries_________________________________________________________________________________
Allergies to vaccinations or medications_________________________________________________________________________
Special diets or medications___________________________________________________________________________________
Vaccination History (provide the date(s) last given below)
Canine:
Rabies:_____/_____/_____ DHLPP (Distemper):_____/_____/_____ Bordetella:_____/_____/_____ Lymes:_____/_____/_____
Heartworm Test:_____/_____/_____ Other (__________):_____/_____/_____
Feline:
Rabies:_____/_____/_____ FVRCP (Distemper):_____/_____/_____ Leukemia:_____/_____/_____
FELV-FIV Test: _____/_____/_____ Other (__________):_____/_____/_____
Pet Information #3
Name___________________________ DOB_____/_____/_____ Breed______________________________ Color______________
Male: Neutered ________ Unaltered________
OR
Female: Spayed________ Unaltered________
Please list any of the following information below about your pet:
Previous illnesses or surgeries_________________________________________________________________________________
Allergies to vaccinations or medications_________________________________________________________________________
Special diets or medications___________________________________________________________________________________
Vaccination History (provide the date(s) last given below)
Canine:
Rabies:_____/_____/_____ DHLPP (Distemper):_____/_____/_____ Bordetella:_____/_____/_____ Lymes:_____/_____/_____
Heartworm Test:_____/_____/_____ Other (__________):_____/_____/_____
Feline:
Rabies:_____/_____/_____ FVRCP (Distemper):_____/_____/_____ Leukemia:_____/_____/_____
FELV-FIV Test: _____/_____/_____ Other (__________):_____/_____/_____
Last updated: April 2014