Eubank Animal Clinic - New Client Information 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. You will sign a print-out of the form when you arrive for your first appointment, and will be required to provide your driver's license information.

Your Name
Street Address
City, State, Zip
Home Phone
Work Phone
Cell Phone
Which phone# is best to reach you during business hours?	Home Cell Work
E-mail
Spouse/Co-Owner Name
Employer Name
Employer Address (in case of emergency)
How did you hear first hear of us?
Were you referred by one of our clients?
Pet Information:
Pet Name
Species	Dog Cat Other
If Other Species
Breed
Color/Markings
Sex	Male Female
Date of Birth
Neutered/Spayed?	Yes No
Microchipped?
Reason for Visit
Previous Veterinarian
Does your pet have a known medical condition and/or on medication?
Please review our terms (read-only)	I hereby authorize the veterinarian to examine, prescribe for, or treat, the above-described pet(s). I assume responsibility for all charges incurred in the care of this animal. I also understand that these charges will be paid at the time of release and that a deposit may be required.
When you are finished, click submit to send the form information

Download PDF Form
Download the PDF version of our New Client Registration to print and fill out, sign and date it at home. Then bring it with you to your first appointment.

> New Client Information Form

(82kb, pdf format, Adobe Reader required)