New Client Form When is your pet's appointment scheduled?* MM slash DD slash YYYY What time is your pet's appointment scheduled?* : Hours Minutes AMPM AM/PMYour Name* First Last Primary Phone*Cell Phone (if different than primary)Your Email* 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 DOB* MM slash DD slash YYYY SSN/DL*Spouse / Co-Owner Name First Last Spouse Date of Birth MM slash DD slash YYYY Spouse primary contact numberHow did you hear about us?* Drove by Yellow Pages Referred Personal Recommendation OtherWhom may we thank?*Other*I hereby authorize the veterinarian to exam, prescribe for and/or treat my animals. I also understand that ALL FEES ARE DUE AT THE TIME SERVICES ARE RENDERED; and agree to reimburse Southern Hills Animal Hospital the fees of any collection agency, which may be based on percentage at a maximum of 30% of the debit, all costs and expenses, including reasonable attorney’s fees, which incur in such collection efforts.* I AgreePatient Information:Name*Species* Canine FelineBreed*Age/DOB*Color*Sex* Male Neutered Male Female Spayed FemaleAny known allergies/serious previous surgery/illness?* Yes NoIf yes, please explain*Up to date on vaccinations?* Yes No I don’t knowAny known medications & dosage amount:*Type of appointment requested* (Establish Doctor/Patient Relationship Puppy or Kitten Shots Wellness Exam Update VAX 2nd Opinion Acute Illness/SickPlease describe*Name/Location of Previous Veterinarian*Authorization to contact previous vet for records* Yes NoPlease upload prior records hereMax. file size: 128 MB.Do you have more than one pet?* Yes NoName*Species* Canine FelineBreed*Age/DOB*Color*Sex* Male Neutered Male Female Spayed FemaleAny known allergies/serious previous surgery/illness?* Yes NoPlease Explain*Up to date on vaccinations?* Yes No I don’t knowAny known medications & dosage amount:*Type of appointment requested* (Establish Doctor/Patient Relationship Puppy or Kitten Shots Wellness Exam Update VAX 2nd Opinion Acute Illness/SickPlease describe*Name/Location of Previous Veterinarian*Authorization to contact previous vet for records* Yes NoPlease upload prior records hereMax. file size: 128 MB.CAPTCHAPhoneThis field is for validation purposes and should be left unchanged.Δ
