New Client and/or Patient Form You can download the form here Client Information Your First and Last Name (required) Secondary Owner's First and Last name (if applicable) Address (required) City (required) State (required) Zip (required) Primary Phone Number (required) CellHomeWork Secondary Phone Number CellHomeWork Your Email (required) Additional Email How did you hear about us Walk by/Live in the neighborhoodGoogleYelpClientOther If client or other please specify here Patient Information Pet's Name (required) Species (required) Breed (required) Color (required) Date of birth/approximate age (required) Sex (required)---MF Neutered/Spayed: (required) ---YN Name of Previous Animal Hospital: Please provide the most recent dates for the following (if you know): Canine DHLPP Vaccination: Rabies Vaccination: Canine Bordetella Vaccination: Canine Lyme Vaccination: Heartworm Test: Result: Does your pet have any allergies to medication or other substances? (required) Is your pet currently on any medications? (required) Has your pet been treated for any major medical problems? (required) Does your pet have any behavior problems? (required) Is your pet's food dry or soft? DrySoft Which brand? How often do you feed your pet? How much do you feed your pet? I understand that the hospital staff will provide an estimate of current and anticipated charges any time I request one. I am requesting that veterinary care be provided for pets presented by me or my agents. I understand I am financially responsible for all services provided at the time of my appointment. Optional Photo/Video Authorization: We know our patients are the cutest in town and we love to show them off! Your signature below authorizes Jewell Animal Hospital’s use of your pets’ photos or videos on promotional material and/or social media. You waive your right to compensation or privacy for images used.