New Clients

Pitman Animal Hospital New Client Form

Primary Client/Owner Contact Info

Please complete the information below.

Primary Client/Owner First Name

Primary Client/Owner Last Name

Primary Client/Owner Pronouns

Primary Owner Address

Address Line 1

Address Line 2

City

State

Zip Code

Primary Client/Owner Phone and Email

Please complete the information below.

Primary Phone

Primary Phone Two

Primary Contact First Email

Primary Contact Secondary Email

Secondary Client/Owner Information

Please complete the information below.

Secondary Client/Owner First Name

Secondary Client/Owner Last Name

Secondary Client/Owner Pronouns

Secondary Owner Address

Address Line 1

Address Line 2

City

State

Zip Code

Secondary Client/Owner Phone and Email

Please complete the information below.

Secondary Phone

Secondary Phone Two

Secondary Contact First Email

Secondary Contact Secondary Email

Emergency Contact Information

Please complete the information below.

Emergency Contact First name

Emergency Contact Last Name

Emergency Contact Pronouns

Emergency Contact First Phone

Emergency Contact Secondary Phone

Relationship to Client

Allergy Screen

Why do we need this info? We often use peanut butter and cheese as a reward or distraction to make visits a pleasant experience for your pet.

Is anyone in the household allergic to Peanut Butter?

Yes

Is anyone in the household allergic to cheese?

Yes

Payment Information

Policies

All services and product sales must be paid for during service/sale.
A deposit of 50% of the total anticipated bill is required for all surgeries and/or hospitalizations.
Emergency cases require a deposit of 50% of the high estimate for the total bill before we can begin treatment*

If necessary, First aid will be initiated immediately without a deposit to save a patient's life.

Payment Methods

We accept cash, personal checks, Visa, Mastercard, Discover, & CareCredit. A photo ID is required for non-cash payment.
All returned checks are subject to a $25 service charge.
If paying by check, provide your Driver's License in the form below.

Driver's License Number for Checks

The First Pet In the Household

Tell us about your first pet.

Pet #1 Name

Date of Birth

Check If Estimated

Estimated DOB

Pet #1 Species

Dog

Cat

Other

If Other, Please Specify

Specify the Breed or Mix

Sex

Male

Female

Spayed/Neutered

Yes

Pet #1 Color(s)

The Second Pet In the Household

Tell us about your second pet.

Pet #2 Name

Date of Birth

Check If Estimated

Estimated DOB

Pet #2 Species

Dog

Cat

Other

If Other, Please Specify

Specify the Breed or Mix

Sex

Male

Female

Spayed/Neutered

Yes

Pet #2 Color(s)

The Third Pet In the Household

Tell us about your third pet.

Pet #3 Name

Date of Birth

Check If Estimated

Estimated DOB

Pet #3 Species

Dog

Cat

Other

If Other, Please Specify

Specify the Breed or Mix

Sex

Male

Female

Spayed/Neutered

Yes

Pet #3 Color(s)

The Fourth Pet In the Household

Tell us about your forth pet.

Pet #4 Name

Date of Birth

Check If Estimated

Estimated DOB

Pet #4 Species

Dog

Cat

Other

If Other, Please Specify

Specify the Breed or Mix

Sex

Male

Female

Spayed/Neutered

Yes

Pet #4 Color(s)

Photo Release

I give Pitman Animal Hospital permission to take photos of my pet and me for Pitman Animal Hospital's social media and marketing purposes. I release Pitman Animal Hospital from any & all claims regarding the use of these photos:

Photo Release

Yes

How Did You Hear About Us?

How did you hear about Pitman Animal Hospital?

Drove by the location

Internet Search/Website

Social Media (Facebook, Twitter)

Referral from a Current Client

Referrer Name

Phone/Mobile

Referral from another Vet

Referrer Name

Phone/Mobile

Other Referral Source

Owner Release

By dating and typing in my name into the form below, I verify that all of the information provided is accurate to my knowledge. I am over the age of 18 and have read the foregoing document & fully understand its contents.

First Name

Last Name

Date / Time

New Client Forms

New Client Scheduling Information

New Client Information Form

Link to Printable PDF Version

Primary Client/Owner Contact Info

Primary Client/Owner Phone and Email

Secondary Client/Owner Information

Secondary Client/Owner Phone and Email

Emergency Contact Information

Allergy Screen

Payment Information

The First Pet In the Household

The Second Pet In the Household

The Third Pet In the Household

The Fourth Pet In the Household

Photo Release

How Did You Hear About Us?

Owner Release

ADDRESS

EMAIL

PHONE

HOURS