CBV - New Client Form

Appointment Information

Fernwood Veterinary Clinic
Thank you for giving us the opportunity to care for your pet. Please help us better meet your pet's needs by taking a moment to share some important information we will need as we support your pet's needs today and in the future.
Do you already have an appointment booked with us? *

Yes No
If no, what day and time would like to request?

Month Day Year Hour Minutes AM/PM Option
Please note that your appointment is not booked until it has been confirmed by

At Home Vet Care
Owners Information
Full Name *

First Name Last Name
Primary Phone Number *

Area Code Phone Number
Alt. Phone Number

Area Code Phone Number
E-mail *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Spouse's Information
Spouse's Name

First Name Last Name
Spouse's Phone Number

Area Code Phone Number
Spouse's E-mail
May we send you reminders, notices, and information by email?
Preferred Pronouns
Pet Information
Please fill out all of the following information about your pet.
Pets Name *
Species *
Breed *
Color *
Birth Date

Month Day Year
Brith Date
Birth Date *

Month Day Year
Sex *

Female Male
Fixed *

Yes No Unsure
Last Vaccinations
Previous Clinic
Medical Issues
Pet Insurance *

Yes No
If yes, which company
Policy #
Microchip/Tattoo #
Have your pets traveled outside of the area? *

Yes No
If yes, where have they traveled?
Do you have any other pets?
Should be Empty:

Appointment Information