Pet Visit New Client Form - Jamaica Plain Animal Clinic 02130

Owner's Name(Required)

First Last

Best Contact Phone Number(Required)

Spouse/Other

First Last

Secondary Phone Number

Address(Required)

Street Address Address Line 2 City State ZIP Code

Email(Required)

**All reminders and appointment confirmations will be sent via email.**

How did you hear about us? If referred by an existing client, please list their full name below.

Pet Health History

Pet's Name(Required)

Date of Birth(Required)

Species(Required)

Cat

Dog

Breed(s)(Required)

Color/Marking(s)(Required)

Sex(Required)

Male

Neutered

Female

Spayed

How long have you had your pet?(Required)

Where did you get your pet?(Required)

Previous Medical Issues/Surgery

Current Medications

Known Allergies (Include vaccine reactions)(Required)

I grant to Jamaica Plain Animal Clinic, LLC, its representatives and employees the right to take photographs of me and/or my pet, and to copyright, use and publish the same in print and/or electronically. I agree that Jamaica Plain Animal Clinic, LLC, may use such photographs of me and/or my pet with or without my name and for any lawful purpose, including, for example, such purposes as publicity, illustration, advertising, and Web content. Do we have your consent to post your pet's photo on social media?

I give consent

I do not give consent

AUTHORIZATION

I hereby authorize the veterinarian to examine, prescribe for and/or treat the pet described above. I assume responsibility for all charges incurred in the care of this animal. I understand that these charges must be paid at the time services are rendered and that a deposit may be required for surgical treatment. If I need to cancel any scheduled appointment or visit for diagnostic imaging I must give 24 hours notice or a $75.00 missed appointment fee will be charged. I understand that if I am late to a scheduled appointment that I may be required to reschedule and pay the missed appointment fee. If I need to cancel a scheduled surgery I must give 48 hours notice or 20% of the low end of the estimate missed surgery fee will be charged.

Signature(Required)

Date(Required)

CAPTCHA

Pet Health History

AUTHORIZATION

Request an appointmentwith us today!

Request an appointment
with us today!