New Client Information
Canine
Mizner Park Veterinary Clinic
Date:
Client Information
1. Name___________________________ Spouse_____________________
2. Address____________________________________________________
3. City____________________________State_________Zip___________
4. Home Phone____________________Work Phone__________________
5. Emergency Contact #_______________Cell Phone__________________
6. E-Mail_____________________________________________________
7. Driver’s License #____________________________________________
How did you hear about us (by whom?): ____________________________
Patient Information
1. Name__________________________ 2. Breed___________________
3. Date of Birth_____________________ 4. Color____________________
5. Sex: (circle one) Male
Male/Neutered
Female
Female/Spayed
Medical History
1. Food______________________________________________________
2. Flea Control________________________________________________
3. Heartworm Prevention________________________________________
4. Previous Surgery____________________________________________
5. Allergies___________________________________________________
6. Previous Medical Problems____________________________________
Do you have any other pets?
Name_______________________ Feline or Canine
Name_______________________ Feline or Canine
ALL FEES ARE DUE WHEN SERVICES ARE RENDERED
New Client Information
Canine
Mizner Park Veterinary
1936 NE 5th Ave
Boca Raton, FL 33431
To be valid, this form must be filled out COMPLETELY, including
what information you are giving us permission to share.
Client’s Legal Name: _______________________________________________
Pet’s Name: _____________________________________________________
Pet’s Microchip #:__________________________________________________
I HEREBY AUTHORIZE MIZNER PARK VETERINARY TO SHARE:
� Any of my veterinary information, including information about:
� Veterinary health diagnoses and treatment
� Dental diagnosis and treatments
� Radiographs
� Lab results
� Appoinment times, dates, and reasons for the visits
� The medications
� Vaccinations
I understand that I may cancel this consent at any time, but that canceling it will
not affect any information that has already been released. I understand that I do
not have to sign this form, and that I should sign it if I allow my veterinarian to
share my pet’s information with the appropriate institution including veterinarians,
groomers, and boarding facilities. Additionally, by signing below I authorize
Mizner Park Veterinary Clinic to obtain records for my pet from previous
veterinarians, groomers, and boarding facilities.
Signature: ____________________________________________
Date: ___________________
Witness: _____________________________________________
Date: ___________________