EmailMe Form - New Client Form

Name *

First Last

Main Phone *

### - ### - ####

Other Phone

### - ### - ####

Work Phone

### - ### - ####

Email

Spouse/Other

First Last

Spouse/Other Phone

### - ### - ####

Spouse/Other Work Phone

### - ### - ####

Spouse/Other Email

Mailing Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code

How did you hear about us? *

Emergency Contact Name *

Emergency Contact Phone *

### - ### - ####

Driver's License Number

State

Pet Information

Pet Name *

Species (Dog, Cat, Other) *

Please select gender *

Male

Male - neutered

Female

Female - spayed

Age *

Breed

Color/Description

Microchip #

How long have you owned this pet? *

Is your pet currently on medication (if so, what)?

Where did you acquire this pet?

Prior surgery or dentistry?

Any prior illnesses or accidents?

What food are you feeding your pet?

Current Groomer

Previous Vet/Hospital

Current Boarding Facility or Daycare Center

Authorization

By typing your name below, you acknowledge the following: I verify that all the above information is accurate. I hereby authorize the veterinarians of The Colony Animal Clinic, PA, and their support staff, to perform diagnostic, therapeutic, and surgical procedures, and to administer and prescribe the medications deemed necessary and advisable for my pet(s) treatment and well being. The nature of such services has been discussed with me, and while I expect all procedures to be done to the best of the professional staff's abilities, I realized that no guarantee or warranty can ethically or professionally be made regarding the results of cure. I authorize the clinic to provide veterinary services as requested or, in emergency circumstances, to follow through with such procedures as are necessary for the well being of my pet on a continuing basis until further advised in writing. As the responsible guardian of this pet(s), I am 18 years old or over. I assume full responsibility for all charges incurred in the care of my pet. I also understand that all professional fees are due at the time services are rendered.

Name

Date Signed

MM / DD / YYYY