Name *

First

Last

Email *

Primary Phone *

Secondary Phone

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone

How did you find out about our hospital? If you were referred by someone, who should we thank?

Referral Name

If other, please explain

Pet Information

Pet's Name *

Species (dog, cat, etc.) *

Breed *

Color *

Age/Date of Birth *

Sex *

Male
Female

Spayed/Neutered?

Yes
No

Does your pet have a microchip identification?

Yes
No

What is the microchip number?

We love using treats during pet appointments. Are there any foods or treats that your pet is sensitive to or cannot have?

Yes
No

If yes, please tell us which foods to avoid:

Previous pet health and vaccine records are important for us to have on file. Please list your pet’s previous veterinary care provider.

Vet Clinic Name

Phone

Would you like us to contact them to help ensure your pet’s medical record is on file at our clinic?

Yes
No

We want to create the best experience possible for your pet. Is there any additional information you would like to tell us about your pet? For example: your pet’s likes/dislikes etc.

Yes
No

If yes, please tell us more about your pet:

Would you like to add information for a second pet?

Yes
No

Pet's Name:

Species (dog, cat, etc.)

Breed

Color

Age or Date of Birth

Sex

Male
Female

Spayed/Neutered

Yes
No

Does your pet have a microchip identification?

Yes
No

What is the microchip number?

We love using treats during pet appointments. Are there any foods or treats that your pet is sensitive to or cannot have?

Yes
No

If yes, please tell us which foods to avoid:

Previous pet health and vaccine records are important for us to have on file. Please list your pet’s previous veterinary care provider.

Vet Clinic Name

Phone

We want to create the best experience possible for your pet. Is there any additional information you would like to tell us about your pet? For example: your pet’s likes/dislikes etc.

Yes
No

If yes, please tell us more about your pet:

Would you like to add a third pet?

Yes
No

Pet's Name

Species (dog, cat, etc.)

Breed

Color

Age/date of Birth

Sex

Male
Female

Spayed/Neutered?

Yes
No

Does your pet have a microchip identification?

Yes
No

What is the microchip number?

We love using treats during pet appointments. Are there any foods or treats that your pet is sensitive to or cannot have?

Yes
No

If yes, please tell us which foods to avoid:

Previous pet health and vaccine records are important for us to have on file. Please list your pet’s previous veterinary care provider.

Vet Clinic Name

Phone

Would you like us to contact them to help ensure your pet’s medical record is on file at our clinic?

Yes
No

We want to create the best experience possible for your pet. Is there any additional information you would like to tell us about your pet? For example: your pet’s likes/dislikes etc.

Yes
No

If yes, please tell us more about your pet:

Would your like to add a fourth pet?

Yes
No

Pet's Name

Species (dog, cat, etc.)

Breed

Color

Age/Date of Birth

Sex

Yes
No

Spayed/Neutered?

Yes
No

Does your pet have a microchip identification?

Yes
No

What is the microchip number?

We love using treats during pet appointments. Are there any foods or treats that your pet is sensitive to or cannot have?

Yes
No

If yes, please tell us which foods to avoid:

Previous pet health and vaccine records are important for us to have on file. Please list your pet’s previous veterinary care provider.

Vet Clinic Name

Phone

Would you like us to contact them to help ensure your pet’s medical record is on file at our clinic?

Yes
No

We want to create the best experience possible for your pet. Is there any additional information you would like to tell us about your pet? For example: your pet’s likes/dislikes etc.

Yes
No

If yes, please tell us more about your pet:

Would you like to add a fifth pet?

Yes
No

Pet's Name

Species (dog, cat, etc.)

Breed

Color

Age/Date of Birth

Sex

Yes
No

Spayed/Neutered?

Yes
No

Does your pet have a microchip identification?

Yes
No

What is the microchip number?

We love using treats during pet appointments. Are there any foods or treats that your pet is sensitive to or cannot have?

Yes
No

If yes, please tell us which foods to avoid:

Pevious pet health and vaccine records are important for us to have on file. Please list your pet’s previous veterinary care provider.

Vet Clinic Name

Phone

Would you like us to contact them to help ensure your pet’s medical record is on file at our clinic?

Yes
No

We want to create the best experience possible for your pet. Is there any additional information you would like to tell us about your pet? For example: your pet’s likes/dislikes etc.

Yes
No

If yes, please tell us more about your pet:

Authorization

At CountryVets our mission is to show veterinary medicine in a positive light and educate others on what behind the scenes veterinary life looks like. One way we do that is with our social media accounts and website. Do we have your permission to use pictures and/or videos of your animals on these platforms? *

Yes
No

Does your pet have its own social media account? If so, we would love to follow it!

Yes
No

Please provide your pet's social media below:

Payment is due in full at the time that services are performed. If being admitted into the hospital, we cannot begin the care of your Pet until you have confirmed your desire to do so by 1) signing the client consent & estimate form, and 2) leaving an initial deposit of 50% of the upper end of the estimate. This is the only way that we have of knowing for certain that you want us to proceed with the care of your Pet. We accept Cash, Visa, MasterCard, Discover, and CareCredit payments. We neither extend credit, nor bill for services. All open invoices are sent to collections after 45 days unless prior arrangements are made. In the event a balance due to CountryVets is unpaid, we may use the services of a Collections Agent and we or they may report to Credit Reporting Agencies. In such cases, client and patient data will be shared, which may include invoices, patient medical records, client identifying data, and any other details obtained during the course of business that are pertinent to this process. *

I have read and accept the financial policy.

New Client Form

Pet Information

Authorization