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New Client Questionnaire

Driver's License #:

PET ASSURE Insurance:

yes

no

How did you hear about us?

Co-Owner Name (first & last):

Co-Owner Phone Number:

Patient Information:

Pet's Name

Pet Species:

Feline

Canine

Pet Breed(s):

Color:

Age / DOB

Is your pet

Male

Female

Male Neutered

Female Spayed

Microchip #:

General Information

If needed, where can we obtain previous medical records for your pet? Previous Veterinarian and Phone Number

Is your pet currently on a monthly heartworm preventative?

yes

no

If yes, which type?

Is your pet currently on monthly flea preventative?

yes

no

If yes, which type?

Is your pet currently on any medications

yes

no

If yes, please list:

Is your pet allergic to any medications?

yes

no

If yes, please list:

Do you have any other pets in the household?

yes

no

If yes, please list:

Texas Veterinary Licensing Act prohibits the disclosure of your name, address, and pet health records to other clinics, grooming, and boarding facilities without your authorization.

Would you allow us to release vaccine records to your boarding kennel and/or groomer?

yes

no

Would you allow us to release your contact information to someone who has found your pet?

yes

no

Would you allow the Panther Creek Pet Clinic permission to use your pet(s) names and pictures for display, public relations and marketing?

yes

no

Full payment is required at the time of service. I understand that the staff will provide me with a treatment plan for estimated charges upon my request. By acknowledging below, I understand that I am financially responsible for all treatment services provided and medication prescribed.

I understand that I am financially responsible for all treatment services provided and medication prescribed.