Client Information Form

Thank you for giving the staff of Quartz Hill Veterinary Clinic
the opportunity to care for your pet(s).
So that we may become better acquainted,
please complete the following.

Name

Spouse's Name

Address

City

State

Zip

Phone

Work Phone

Cell Phone

Place of Employment

Best Time to Reach You

Driver's License #

E-Mail Address

All Fees Are Due At The Time Services Are Rendered

Please indicate choice of payment

How did you become aware of our clinic?

If by Personal Recommendation, whom may we thank?

	PET #1	PET #2	PET#3
NAME
BREED
DATE OF BIRTH
COLOR
SEX; SPAYED OR NEUTERED

YOUR DOG'S VACCINATION HISTORY:

	PET #1	PET #2	PET#3
RABIES
DHLP PARVO CORONA
BORDETELLA
INTRA TRAC II
FECAL (STOOL SAMPLE)
HEARTWORM TEST/PREVENTION?

YOUR CAT'S VACCINATION HISTORY:

	PET #1	PET #2	PET#3
RABIES
DIST-RHINO CHLAMYDIA
LEUKEMIA TEST
LEUKOCELL
FECAL (STOOL SAMPLE)

Our pet(s) is:

Member of our family

Child's pet

Backyard pet

Any previous serious illnesses or surgeries?

Any allergies to vaccinations or medications?

Is your pet on any special diets or medications?

Would you like to be present during treatment of your pet?

Yes

No

Client Signature (to be signed on arrival at our office)

Date

Do you already have a appointment?

Yes

No

If yes, please fill in the date and time of your appointment.

If no, would you like us to call you to schedule an appointment?

Yes

No

* Indicates Response Required


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