New Client Form - Animal Health Clinic of Funkstown

Date of Appointment*

Owner name*

Prefix First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Primary phone*

Secondary phone

I would like to receive appointment confirmation via text*

Yes
No

Employer’s name

Work phone

Employer’s address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Co-Owner/Spouse Name

First Last

Co-Owner/Spouse Phone

Spouse's employer's name

Spouse work phone

Spouse employer’s address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Emergency contact name

First Last

Emergency phone

Are you eligible for a senior citizen discount? (65 years or older)

Yes
No

Are you eligible for a military discount? (active or retired military with ID)

Yes
No

E-mail 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?

Pet Information

Pet’s Name

Age/Birthdate

Species

Other

Breed

Sex

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?

Other

Current Medications

Other

Is your pet current on their rabies?

Yes
No

Rabies vaccine expiration date

Is your pet microchipped?

Yes
No

Microchip Number (if known)

Pet Insurance Company

Policy Number

May we use your pet's photo on Facebook, website, or other media?

Yes
No

Method of payment

Cash
Card
Check
CareCredit

I hereby authorize Animal Health Clinic to examine, prescribe for and treat my pets. I assume responsibility for all charges incurred in the care of my animals. I also understand that these charges will be due at the time of release and that a deposit may be required for surgical treatment or hospitalization. We will gladly prepare a written estimate for your pet's care at any time. Just ask one of our staff members.

Phone

This field is for validation purposes and should be left unchanged.