New Client Form

Animal Care Center Veterinary Clinic

5498 Commercial St. SE Salem, Oregon 97306 We're one block south of Wal-Mart on Commercial St.	phone: 503.371.1988 email: accvetclinic.com@comcast.net fax: 503-371-3900
Your last name	Your first name
Spouse's last name	Spouse's first name
Your mailing address
Home phone	Work phone
Cell phone	Work phone
Driver's license #/ state	E-mail address
Your employer	Spouse's employer
Employer address	Employer address
How did you become aware of our clinic?	What method of payment will you be using for today's charges?
If we were recommended to you by someone, please list their name so we may thank them:	I will assume full responsibility for all charges incurred in the care of my animals. I also understand that all charges will be paid in full at the time of discharge and that a deposit may be required for surgical procedures and hospitalized pets.
Please check if you would like us to contact you via e-mail with information about promotions, appointment reminders, test results, etc.	I have carefully read and agree to all of the above statements. Signature
Your Pet's Information
	Pet #1	Pet #2
Name
Species (canine, feline, etc.)
Breed
Color
Birthdate or age
Sex
Spayed or neutered?
Vaccination & Test History	Date	Date
Canines
DHLPP/ Cv
Bordetella (kennel cough)
Lyme disease
Heartworm test date/ results	positivenegative	positivenegative
Canines & Felines
Rabies
Felines
FVRCPP
FeLV (feline leukemia)
FIP
FeLV/ FIV test date(s)/ results	FeLV+FeLV-	FeLV+FeLV-
FeLV/ FIV test date(s)/ results	FIV+FIV-	FIV+FIV-
FIP test date/ results	FIP+FIP-	FIP+FIP-
What brand of food do you feed?
How much do you feed (how many cups or cans)?
Please list any medications your pet is currently taking.
When was the last dose given?
What are you currently using for flea control?
Does your pet have any medical conditions or history that we should be aware of?
When you have completed this form, please click the following button to submit the form to us via e-mail. Or, if you prefer, you can print the form and mail it, fax it, or bring it in to us.