NEW CLIENT QUESTIONNAIRE

OWNER'S INFORMATION

Owner's Name *

Co-Owner

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

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Phone Number

Email Address *

PET'S INFORMATION

Pet's Name

Breed

Color

Date of Birth

SexChoose…MaleFemale

Neutered/SpayedChoose…YesNo

Do you ever find ticks on your pet?

YesNo

Have you missed any monthly dose of heartworm preventative (K9 only)

YesNo

What food are you currently feeding your pet?

Does your pet drink from water outdoors, such as ponds, puddles, rivers or creeks?

YesNo

Does your pet ever visit a groomer or boarding facility?

YesNo

Does your pet have a microchip?

YesNo

Name of previous veterinary hospital?

Have you been to our hospital before?

YesNo

Do we have permission to use your pet’s picture on social media?

YesNo

Do you have pet insurance?

YesNo

If yes, what company?

How did you hear about Milford Animal Hospital? (Personal Recommendation? If so, please list the name of the person who recommended you so we can send them a thank you!!)

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