New Client Form

* Indicates required field

Owner Name *

First

Last

Home Phone *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Cell Phone *

Cell Phone Provider *

Email *

Employer *

Owner DOB *

Driver's License *

Spouse's Name *

First

Last

Cell Phone *

Employer *

In Case of Emergency Contact *

Phone Number *

Pet Name *

Breed *

Color/Markings *

Pet DOB *

Species *

Sex *

Is your pet on any medications? *

Yes No

If yes, please list medications here: *

Does your pet have any chronic problems? *

Yes No

If yes, please list problems here: *

Is your pet allergic to any medications or vaccines? *

Yes No

If yes, please list allergies here: *

Please describe your pet's temperament at the vet. *

Please upload any vaccine records or history for your pet below:

Upload File *

Max file size: 20MB

How many pets do you have in your household? Please list their names, breeds, and ages. *

May we send appointment reminders to your email address? *

May we take pictures of your pet to put in our system, on our website, and/or Facebook? *

How did you hear about us? *

Forms of Payment Accepted
▢ Cash ▢ Check ▢ Credit (Visa, MasterCard, American Express, Discover) ▢ CareCredit
In the even of default on any payments due, I agree to pay Salem Veterinary Hospital any and all added costs of collection including but not limited to 33.33% attorney fees. Salem Veterinary Hospital charges $35 for returned checks. For clients with pet insurance, we are happy to provide you with the necessary documentation for you to submit an insurance claim.

Electronic Signature *

First

Last

Please print out a copy of this form before clicking "submit", and be sure to bring the form with you to your scheduled appointment.

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