Armonk Veterinary - New Client Form

New Client Form
To ensure the best care possible for your pet, please take the time to complete this form so we have as much information as possible. When done, click submit to send the form information to us.

Your Name

Street Address

City, State, Zip

Home Phone

Work Phone

Mobile Phone

E-mail

Spouse/Partner Name

Emergency Contact:

Emergency Contact Name
(if other than spouse)

Emergency Conact's Relation to You

Emergency Contact's Phone

Is this person authorized to make decisions about your pet’s health? Yes No

Were you referred to AV by one of our clients?

# of Pets in Your Household

Pet Information:

Pet Name

Species

Dog Cat Other

If Other Species

Breed

Sex

Male Female

Date of Birth

Neutered/Spayed?

Yes No

Microchipped?

Please describe your pet's daily diet

Pet Health History:

Does your pet have any known allergies?

Can you provide us with your pet's vaccination history?

Please tell us what (if any) medications your pet is currently taking

Please check any symptoms or problems that you have noticed about your pet recently

	Behavior Problems
	Bleeding Gums
	Breathing Problems
	Coughing
	Diarrhea
	Eye bulging or bloodshot
	Gagging
	Lack of Appetite
	Lethargic Behavior
	Limping
	Loss of Balance
	Scooting
	Scratching Excessively
	Shaking Excessively
	Sneezing
	Thirst and/or Urination Increase
	Vomiting
	Weakness
other symptoms (please explain)

Please tell us the reason for your visit

When you are finished, click submit to send the form information

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