Name *

First

Last

Spouse/Co-Owner's Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Primary Phone *

Secondary Phone *

Spouse/Co-Owner's Phone

Email *

Your email will only be used for hospital-related correspondence and medical reminders.

Preferred payment method (select all that apply) *

Cash
Check
Credit/debit card
CareCredit

Please note that all fees are due at time of services rendered.

Pet's Name *

Species *

Canine
Feline

Breed *

Color

Age/Date of Birth

Sex *

Male
Male (neutered)
Female
Female (spayed)

Is your pet microchipped? *

Yes
No

Is your pet allergic to any medications or vaccinations? *

Yes
No

If yes, please explain *

Is your pet currently taking any medications? *

Yes
No

If yes, please list all medications (name, dosage, and frequency) *

I authorize Abri Veterinary Hospital to release medical information to other hospitals, groomers, and kennel facilities. *

I authorize
I do not authorize

I grant Abri Veterinary Hospital permission to post my pet's pictures and stories on the hospital's social media pages. *

I grant permission
I do not grant permission

I authorize Abri Veterinary Hospital to release basic contact information (phone number) in the event that my animal is lost and recovered by another individual. *

I authorize
I do not authorize

As a new client, I understand that is my responsibility to provide previous/additional vaccine records. I also understand that if proof of rabies vaccination can not be provided that a rabies vaccine will be done prior to any additional services. *

I have read and understand.

Do you give Abri Vet Hospital permission to take photos and share those photos on social media or other various marketing materials? *

I give permission
I do not give permission

Signature *

Date *

New Client Form

We look forward to seeing you!

AAHA-accredited veterinary care in Winston-Salem, NC.

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