Veterinary Forms | South Bay Veterinary Hospital

May we contact you at work?

Yes

No

Place of Employment

Co-Owner Name (first & last):

Co-Owner Phone Number:

Do you want our clinic to send Vaccine reminders for your pet(s)?*

Yes

No

Do we need to obtain records from a previous veterinarian?*

Yes

No

If yes, contact information:

Pet's Name

Species

Sex

Female Intact

Female Spayed

Male Intact

Male Neutered

Breed

Color

Age / DOB

Microchip

Yes

No

Unknown

Pet's Name

Species

Sex

Female Intact

Female Spayed

Male Intact

Male Neutered

Breed

Color

Age/DOB

Microchip

Yes

No

Unknown

Are any of your pets currently on any medication? Who?

How did you hear about us?

Internet Search

Drive By

Client Referral

Other

If you were referred by a client, what is their name?

Do you qualify for a discount?

Military-Active/Retired

Senior citizen 60yrs +

I understand that my pet’s picture may be used on social media sites.

YES, you can use my pet's photo on social media.

NO, do not use my pet's photo on social media.

Payment is expected at the time of service
WE ACCEPT THE FOLLOWING FORMS OF PAYMENT:
VISA, MASTERCARD, AMERICAN EXPRESS, DISCOVER, CARE-CREDIT, CHECK & CASH

AUTHORIZATION
I hereby authorize the veterinarian to examine, prescribe for, or treat the above-described pet(s). I assume responsibility for all charges incurred in the care of this animal. I also understand these charges will be paid at the time of release and that a deposit may be required for surgical treatment. In the event of default of payment and/or failure to pay, I the undersigned, agree to pay the costs of collection including court costs and reasonable attorney fees to be determined by a court of law.*

I agree with the above

New Client Form

May we contact you at work?

Place of Employment

Co-Owner Name (first & last):

Co-Owner Phone Number:

Patient Information:

Do you want our clinic to send Vaccine reminders for your pet(s)?*

Do we need to obtain records from a previous veterinarian?*

If yes, contact information:

Pet 1

Pet's Name

Species

Sex

Breed

Color

Age / DOB

Microchip

Pet 2

Pet's Name

Species

Sex

Breed

Color

Age/DOB

Microchip

Are any of your pets currently on any medication? Who?

General Information

How did you hear about us?

If you were referred by a client, what is their name?

Do you qualify for a discount?

I understand that my pet’s picture may be used on social media sites.