New Client Form "*" indicates required fields Client InformationName* First Last Date Of Appointment* MM slash DD slash YYYY Time of Appointment* Hours : Minutes AM PM AM/PM Phone #*Secondary Phone #Email* Co-Owner/Spouse First Last Co-Owner/Spouse Phone #Co-Owner/Spouse Secondary Phone #Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Best time to reach you*How did you hear about us?*Previous ClientDrove ByGoogleYelpWebsiteSocial MediaReferralName of Referral* First Last Patient InformationPet Name*Date of Birth*Sex* Male Female Spayed / Neutered* Yes No Species* Dog Cat BreedColor/Markings*Are vaccinations current?* Yes No Vaccination/Health HistoryAccepted file types: pdf, doc, docx, jpg, Max. file size: 256 MB. Please uploadAny previous illness or surgery?On any special diet?Allergies to medication?What would you like us to do if another Veterinary Hospital, or your insurance company requests your pets' records?I consent for my pets' records to be sent when requested. This is the fastest way for other hospitals that need to treat your pet to get their previous medical history, and allows insurance claims to be processed efficientlyI ask that you contact me first. I understand this will delay my records getting sent, and my pets' records will not be sent until I consent every timeALL FEES ARE DUE AT THE TIME SERVICES ARE RENDEREDIn the event of any balance due hereunder is not paid at the completion of the visit or hospital stay, the undersigned agrees to pay all costs including said unpaid balance and finance charges. Monthly billing not available Veterinary Service during nighttime hours and or weekends is provided at the discretion of the veterinarian in charge. Continuous presence of personnel may not provided during these hours. I give my consent to Pomona Valley Veterinary Hospital to use my pets images on social media via facebook, website, pinterest or twitterYesNoConsent* I understand Pomona Valley Veterinary Hospital uses automated text and email messages to notify me of any upcoming appointments or reminders. I can choose to opt out at any moment and no longer receive such messages upon receiving them.Signature*Date* MM slash DD slash YYYY
