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New Client Form

Thank you for choosing Central Texas Animal Hospital. We take very seriously the trust you have placed in us.
Please tell us a little about you and your pet(s):

Pet Owner's Name:   Home Phone:  
Address:   City:  
State:   Zip:  
Cell #:   Work#:  
DL#:   Spouse/Roomate:  
Email Address:        
How did you hear about us? (Whom may we thank?)  
         
  Work/Live in the area        
  Welcome Letter/Postcard/Welcome Wagon    
  Internet (Directory? Search Engine?)  
  Personal Referral    
  Other    
If you have an appointment scheduled with us, when is your appointment?

Patient Information

Name:   Pet's Birthdate or approx age:  
Species: Dog   Cat   Breed:  
Weight:   Sex:  
Color:   Microchip: Yes   No  
Spayed/Neutered? Yes   No        
Name:   Pet's Birthdate or approx age:  
Species: Dog   Cat   Breed:  
Weight:   Sex:  
Color:   Microchip: Yes   No  
Spayed/Neutered? Yes   No        
Name:   Pet's Birthdate or approx age:  
Species: Dog   Cat   Breed:  
Weight:   Sex:  
Color:   Microchip: Yes   No  
Spayed/Neutered? Yes   No        

I understand that payment is due at the time of visit and that a deposit is required for estimated services of $100.00 or more. I am these pet's owner or ownerís agent and as such am authorized to approve of any diagnostics or treatment for this animal. I am at
least 18 years of age. I authorize the release of my pet's medical information to other pet-related services (kennels, trainers, etc) who are actindividuals in the event that my pet becomes lost.

Fill in your Name: (constitutes as your signature)

How will you be paying for this visit? MC/Visa/Discover:

 
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