Client/Patient Information

Client Registration Level*

New Client
Current Client - New Pet
Previous Client (>2 years since last visit)

Owner Name*

First Last

Email*

Which phone numbers would you like to share with us?*

Select All
Cellular
Landline
Work
Spouse/Other

Cellular*

Landline*

Work*

Spouse*

Credit Policy: We ask that all fees be paid at the time of service. We accept cash, personal checks (with identification), Visa, MasterCard, Discover, American Express, and CareCredit. Exceptions must be cleared with the Practice Manager prior to service. Past due accounts are subject to late fees and those turned over to collections are subjection to collection and/or legal fees.*

I have read this statement and understand

Social Media/Photo Permission: Do we have your permission to post photos of your pet online?*

Yes
No

Client Information

Employer

Account Holder's Date of Birth

Home Mailing Address

Street Address Address Line 2 City State ZIP Code

Would you like to add a second person to the account?*

Yes
No

Spouse/Other

Spouse Employer

Pet Information

Pet's Name*

Species*

Canine
Feline

Breed

Color

Date of Birth/Age

Gender*

Male
Female
Unsure

Spayed or Neutered?*

Yes
No
Unsure

Any Known Allergies/Reactions?*

Yes
No

If Yes, Please Elaborate:

Is your pet's Rabies vaccination up to date?*

Yes
No
Unsure

When was the last time your pet was seen by a veterinarian?*

Who was your pet's previous veterinary clinic?*

Would you like to add information for a second pet?*

Yes
No

Pet's Name*

Species*

Canine
Feline

Breed

Color

Date of Birth/Age

Gender*

Male
Female
Unsure

Spayed or Neutered?*

Yes
No
Unsure

Any Known Allergies/Reactions?*

Yes
No

If Yes, Please Elaborate:

Is your pet's Rabies vaccination up to date?*

Yes
No
Unsure

When was the last time your pet was seen by a veterinarian?*

Who was your pet's previous veterinary clinic?*

How Would You Like To Receive Reminders for Your Pet's Care?*

Email
Text Message
Post Card
Phone Call
I would not like to receive reminders

Monday	8:00am – 5:00pm
Tuesday	8:00am – 5:00pm
Wednesday	8:00am – 5:00pm
Thursday	8:00am – 5:00pm
Friday	8:00am – 5:00pm
Saturday	Closed
Sunday	Closed

Client/Patient Information

Client and Patient Registration

Client Information

Pet Information

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El Dorado Animal Clinic

Client/Patient Information

Client and Patient Registration

Client Information

Pet Information

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Location

El Dorado Animal Clinic