New Client Form

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Owner *

First

Last

Primary Phone *

Cell Phone

Work Phone

Employer *

Spouse

First

Last

Cell Phone

Work Phone

Employer *

Address

Address Line 1

Address Line 2

City

State

Zip Code

E-mail Address To Receive Health Reminders *

Pet Information

Pet’s Name *

Species (dog, cat, etc.) *

Breed *

Color *

Date of Birth

Sex *

Male
Neutered Male
Female
Spayed Female

Sex Altered *

Does Pet Have Microchip *

List Any Known Allergies (Vaccine, Drugs, Other):

List All Major Previous Medical Problems:

Previous Veterinarian:

All fees are due upon release of the patient.
All check payments require two forms of identification. No out of state or first time client checks accepted.

How did you find out about our hospital? If you were referred by someone, who should we thank? *

Photo Release: I grant Melrose Veterinary Hospital the right to take photographs of me and/or my pet, and to copyright, use, and publish the same in print and/or electronically. I agree that Melrose Veterinary Hospital may use such photographs of me and/or my pet with or without my name and for any lawful purpose, including, for example, such purposes as publicity, illustration, advertising, and web content

Initial Here:

It is our policy to provide you with an estimate of fees upon request for any case where inhospital treatment, emergency care, surgery or hospitalization will be provided. A deposit prior to treatment may be required depending upon the amount of the estimate

I have read and accept the financial policy.

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Clients Signature *

Date *

New Client Form

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Contact Information

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