New Client Form

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New Client Form

CLIENT INFORMATION

Name *

First

Last

Primary Phone *

Home (Contact)

Cell (Contact)

Email *

Spouse Name

Spouse Cell

Mailing Address

Address Line 1

Address Line 2

City

State

Zip Code

Select your preferred contact method

Call
Text
Email

PATIENT INFORMATION

Pet Name

Species

Dog
Cat
Other

If Other, please specify

Date of Birth or Age

Gender

Female
Female Spayed
Male
Male Neutered

Breed

Color

Name of Previous Veterinarian

Phone Number of Previous Veterinarian

Upload previous medical records

Click or drag a file to this area to upload.

How did you hear about us?

SOCIAL MEDIA RELEASE

Can we post your pet’s picture on Facebook / Instagram to welcome them as a new patient?

I hereby grant Wellington Veterinary Hospital permission to post my pet’s picture or video on socialmedia (Instagram, Facebook, etc.). Note: Owner information or medical history will not be posted. * *

MEDICAL AUTHORIZATION

I hereby authorize the veterinarian to examine, prescribe, and treat the above described animal. I assume responsibilities for all charges incurred by the care of my pet, and understand that these charges will be paid in full at the time services are rendered.

I also understand a deposit may be required for any surgical or emergency treatment.

Signature *

Date *

Ready for a visit?

Wellington Veterinary Hospital is a full-service veterinary hospital in the Wellington, Colorado community. We deliver award-winning, high-quality, and innovative care for your pet with compassion.

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