New Client Form

Owner*:

 Mr.  Mrs.  Miss  Ms.

SS#:

Street Address:

City, State, Zip:

Home Phone:

Cell Phone:

I would like to receive appointment confirmation via text:  Yes  No

Employer's Name:

Employers full address:

Work Phone:

Co-Owner/Spouse Name:

SS#:

Co-Owner Home Phone:

Co-Owner Cell Phone:

Co-Owner Employer's Name:

Employer's Address:

Emergency Contact Name:

Emergency Contact Phone Number:

Are you eligible for a senior citizen discount? (65 or older)  Yes  No

Are you eligible for a military discount? (active or retired military with ID)  Yes  No

Email Address:  

Providing us with your e-mail address will allow you FREE online access to your own PET PORTAL as well as our FUNKSTOWNVET app giving you access to your account, your pet’s records, and our LOYALTY REWARDS program. We will not sell your e-mail address to anyone and will only be used by our office for occasional information on events and special offers

How did you hear about us?

 Yellow Pages  Herald Mail/What’sNxt  Local event TV Sign  Our Website  101.5 BOB Rocks  92.1FM  AAHA Church Bulletin  Facebook/Instagram  Referral - Individual we may thank? 

Pet's Name:

Age/Birthdate:

 Dog  Cat Other       Male  Neutered  Female  Spayed

Color(s):  Distinguishing Markings: 

Previous Veterinarian:

 I give permission to call previous vet to obtain a current copy of my pet's records

Has your pet had any of the following: Allergies  Heartworm Disease Lyme Disease  Kidney Issues  Liver Issues  Glaucoma Fleas or ticks  Heart Disease  Feline Leukemia  FIV  Parvo disease  Other 

Current Medications?  Interceptor  Heartgard  Proheart  Frontline Plus  Credelio  Simparica  Revolution  Rimady  PPA OTC vitamins  Joint supplements  OTC pain medication  Other 

Is your pet current on their rabies?  Yes  No Expiration date: 

Is your pet microchipped?  Yes  No Microchip (if known) # 

 Pet Insurance Company:  Policy: 

May we use your pet's photo on Facebook, website, or other media?  Yes  No

Method of Payment:  Cash  Credit/Debit Card  Check  CareCredit