New Client Form

Client (Human) Name:*

First

Last

Address:*

Street Address

Apt #

City

State

Zip

Cell Number:

Other Number(s):

Primary Email Address:*

Other Authorized Person(s) you would like to add to your chart:

Name

First

Last

Number

Name

First

Last

Number:

Please answer the following questions:

Pet's Name*

Species*

Dog
Cat

Breed*

(or Longhair/Shorthair for non-purebred cats)

Color*

Birthday (or Age)*

Gender*

Male
Female

Spayed or Neutered*

Yes
No

Would you like to add a second pet?

Yes

Pet's Name*

Species*

Dog
Cat

Breed*

(or Longhair/Shorthair for non-purebred cats)

Color*

Birthday (or Age)*

Gender*

Male
Female

Spayed or Neutered*

Yes
No

How did you hear about us?*

May we release your records to any third party?*

NOTE: A third party may be a groomer, doggy daycare facility, other animal hospitals/referral centers, etc.

Yes
No, I wish to be contacted first

Photo Consent:*

We love to take photos of our patients for educational purposes, marketing, social media, our website and medical charting reasons. No personal information will be used without your permission. Do you consent to allowing us to take and/or use photos of your pet for the above described purposes?

Yes
No

Are you a Senior Citizen (65 or older)?*

Yes
No

Are you active or retired Military?*

Yes
No

Who was your previous veterinary clinic?

Previous Medical Records?

In order to facilitate your appointment in an efficient manner, please upload any medical records you may have for your pets. If you are unable to upload your pet’s medical records, please bring them with you to your appointment or contact your previous veterinary clinic and have your pet’s records either emailed to [email protected].

Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 50 MB.

Authorization For Treatment*

I hereby authorize the veterinarian(s) of Companion Round Lake to examine, prescribe, treat and perform procedures for my pets as medically deemed necessary and authorized by me. I understand that I am responsible for all costs incurred and that payment is due at time of services rendered. I understand that Companion Round Lake does NOT offer payment plans of any kind and that I may be asked to pay a deposit prior to performing certain treatments or procedures.

I agree.

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Email

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Complete the New Client Form so we can Better Assist You

Other Authorized Person(s) you would like to add to your chart:

Please answer the following questions: