GEORGETOWN VETERINARY HOSPITAL

53 Redding Road, Redding, Ct. 06896 (203)-544-9098

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New Client Information Sheet

Welcome to Georgetown Veterinary Hospital. In order for us to give your pet the best care, kindly take a few minutes to complete the following form:

Owner's name:(required)

Spouse/Partner Name:

Address(required)

How did you learn about our clinic?

If recommended, by whom:

Home Phone:

Cell:(required)

Fax:

Email:(required)

Pet's Name:(required)

Pet's Date of Birth:(required)

Breed:

Color:

Sex:

Species:

Is your pet spayed or neutered?

Yes No Not Sure

Is your pet current on his/her's vaccines?

Yes No Not Sure

Canine-DHP/P (Distemper/Parvo) Date:

Rabies Vaccine Date:

Lyme Vaccine Date:

Canine Bordetella (Kennel Cough) Date:

Canine Leptospirosis Vaccine Date:

Canine Heartworm Test Date:

Feline FVRCP (Distemper/Respiratory) Date:

Feline Leukemia Vaccine Date:

Is your pet on any medications or supplements? (including vitamins, coat products, nutritional supplements, and the like). If yes, then please list below.

Yes No

Please list additional medications and supplements:

Heartworm preventive medicine

Yes No

Flea and Tick preventative medicine

Yes No

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Thank you for your time. Please call us at 203-544-9098 to schedule an appointment.

We at GVH hope that this is the beginning of a long and happy relationship!!!