New Client Form Owner InformationDate MM slash DD slash YYYY Owner First Last Co-Owner/Spouse First Last 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 PhonePhone number is a Cell Home Work Alternative PhoneAlternative phone number is a Cell Home Work Email Preferred communication? Email Text Phone Call If a picture is taken of your pet, can we share it to social media (facebook, etc.)? Yes No Pet Information/Health HistoryName of PetType of Pet Dog Cat Other If OtherBreedColor/MarkingsApproximate Age/BirthdateMy pet is a Male Female Is your pet Neutered/Spayed? Yes No Not Sure Vaccination History Has your pet been vaccinated within the last 12 months? Rabies vaccination is required by law Yes, Vaccinations are current No, Vaccinations are NOT current I’m not sure Medical HistoryDoes your pet have any prior medical conditions, illness or surgery?Is your pet currently taking any medications or on a special diet?Referral InformationPlease tell us how you learned about Barkin’ Wellness Waggin’ I’m a current client Friend or Relative Website Internet (Google) Internet (Facebook) Clinic Van Shelter/Rescue Other If OtherAuthorizationI hereby authorize the veterinarian to examine, prescribe for or treat the above described pet, following consultation and approval by me. I assume responsibility for all charges incurred in the care of this animal. I also understand that these charges will be paid at the end of the wellness visit. Signature of OwnerDate MM slash DD slash YYYY Business HoursMonday: 9AM-5PM Tuesday: 9AM-5PM Thursday: 12PM-7PM Friday: 9AM-5PM Wednesday, Saturday & Sunday: Closed AppointmentsWe will do our best to accommodate your busy schedule. Please schedule an appointment today! Request Appointment
