New Client Form

Owner's Name

Name*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Cell Phone*

Home Phone

Email*

Enter Email Confirm Email

Spouse/Partner Name

First Last

Spouse/Partner Cell Phone

Emergency Contact

Emergency Contact Name (if other than spouse)

Emergency Conact's Relation to You

parent, friend, etc...

Emergency Contact's Phone

Is this person authorized to make decisions about your pet’s health?

Yes
No

Were you referred to AV by one of our clients?

if so, by whom?

# of Pets in Your Household

#dogs, #cats, other...

How many pets are you registering (max. 5)

Pet #1 Information

Pet's Name*

Species*

If other species, please specify

Breed (if known)

Sex

Date of Birth or Age (if known)

Special Identification (tattoo, microchip, etc.)

Please describe your pet's daily diet. (brand, wet/dry, serving size, servings/day)

Pet Health History

Does your pet have allergies or drug reactions?

Yes
No

If Yes, please list the allergies and reactions

Is your pet on any medication or supplement?

Yes
No

If Yes, please list the medication or supplement

Please check any symptoms or problems that you have noticed about your pet recently

Are there any current or past medical conditions of which we should be aware?

Yes
No

If Yes, please comment on the condition(s) and indicate if they are current or past conditions

Please use the following box to give us any other relevant information about your pet

Pet #2 Information

Pet's Name*

Species*

If other species, please specify

Breed (if known)

Sex

Date of Birth or Age (if known)

Special Identification (tattoo, microchip, etc.)

Please describe your pet's daily diet. (brand, wet/dry, serving size, servings/day)

Pet Health History

Does your pet have allergies or drug reactions?

Yes
No

If Yes, please list the allergies and reactions

Is your pet on any medication or supplement?

Yes
No

If Yes, please list the medication or supplement

Please check any symptoms or problems that you have noticed about your pet recently

Are there any current or past medical conditions of which we should be aware?

Yes
No

If Yes, please comment on the condition(s) and indicate if they are current or past conditions

Please use the following box to give us any other relevant information about your pet

Pet #3 Information

Pet's Name*

Species*

If other species, please specify

Breed (if known)

Sex

Date of Birth or Age (if known)

Special Identification (tattoo, microchip, etc.)

Please describe your pet's daily diet. (brand, wet/dry, serving size, servings/day)

Pet Health History

Does your pet have allergies or drug reactions?

Yes
No

If Yes, please list the allergies and reactions

Date of last vaccines (if known)

What vaccines were given at this time

Is your pet on any medication or supplement?

Yes
No

If Yes, please list the medication or supplement

Please check any symptoms or problems that you have noticed about your pet recently

Are there any current or past medical conditions of which we should be aware?

Yes
No

If Yes, please comment on the condition(s) and indicate if they are current or past conditions

Please use the following box to give us any other relevant information about your pet

Pet #4 Information

Pet's Name*

Species*

If other species, please specify

Breed (if known)

Sex

Date of Birth or Age (if known)

Special Identification (tattoo, microchip, etc.)

Please describe your pet's daily diet. (brand, wet/dry, serving size, servings/day)

Pet Health History

Does your pet have allergies or drug reactions?

Yes
No

If Yes, please list the allergies and reactions

Date of last vaccines (if known)

What vaccines were given at this time

Is your pet on any medication or supplement?

Yes
No

If Yes, please list the medication or supplement

Please check any symptoms or problems that you have noticed about your pet recently

Are there any current or past medical conditions of which we should be aware?

Yes
No

If Yes, please comment on the condition(s) and indicate if they are current or past conditions

Please use the following box to give us any other relevant information about your pet

Pet #5 Information

Pet's Name*

Species*

If other species, please specify

Breed (if known)

Sex

Date of Birth or Age (if known)

Special Identification (tattoo, microchip, etc.)

Please describe your pet's daily diet. (brand, wet/dry, serving size, servings/day)

Pet Health History

Does your pet have allergies or drug reactions?

Yes
No

If Yes, please list the allergies and reactions

Date of last vaccines (if known)

What vaccines were given at this time

Is your pet on any medication or supplement?

Yes
No

If Yes, please list the medication or supplement

Please check any symptoms or problems that you have noticed about your pet recently

Are there any current or past medical conditions of which we should be aware?

Yes
No

If Yes, please comment on the condition(s) and indicate if they are current or past conditions

Please use the following box to give us any other relevant information about your pet

Monday	8:00am – 6:00pm
Tuesday	8:00am – 6:00pm
Wednesday	8:00am – 6:00pm
Thursday	8:00am – 6:00pm
Friday	8:00am – 5:00pm
Saturday	8:00am – 2:00pm
Sunday	Closed

Contact Us

New Client Form

Owner's Name

Emergency Contact

Pet #1 Information

Pet Health History

Pet #2 Information

Pet Health History

Pet #3 Information

Pet Health History

Pet #4 Information

Pet Health History

Pet #5 Information

Pet Health History

In this section

In the News

It’s International Assistance Dog Week!

It's National Mutt Day!

Our Blog

Pet Health Library

New Client Form

Owner's Name

Emergency Contact

Pet #1 Information

Pet Health History

Pet #2 Information

Pet Health History

Pet #3 Information

Pet Health History

Pet #4 Information

Pet Health History

Pet #5 Information

Pet Health History

Share

In this section

In the News

It’s International Assistance Dog Week!

It's National Mutt Day!

Our Blog

Pet Health Library