New Client Form

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New Client Form

Clayton Animal Hospital is committed to exemplary care for your pet while providing the best experience as possible for them. Below are a series of questions that will help our staff better serve your pet.

Name *

First

Last

Email *

Cell Phone *

Home Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

How did you learn about our practice?

Number of pets (Please specify by type) *

Primary reason for visit *

Patient Information

Patient Name *

Species *

Cat
Dog
Other

If other, please specify. *

Sex *

Male
Neutered Male
Female
Spayed Female

Age/Date of Birth *

Breed *

What age was the pet obtained? *

Where was the pet obtained? *

Friend
Breeder
Human Society
Other

If other, please specify. *

Describe your pet’s diet: *

List your pet’s current medications:

Please check any symptoms or problems you’ve noticed with your pet: *

Appetite Loss
Gums Bleeding
Urination Increase
Depression
Scratching
Gagging
Thirst
Coughing
Scooting
Sneezing
Breathing Problems
Loss of Balance
Weakness
Shaking Head
Behavioral Changes
Limping
Vomiting
Diarrhea
Other

If other, please specify. *

Pet's History *

Distemper
Parvovirus (Dog)
Rabies (Dog/Cat)
Feline Leukemia Test
FVRCP (Infectious Disease - Cat)
Dental
Other

If other, please specify. *

Prior Surgery or Illness

Authorization

I hereby authorize the veterinarian to examine, prescribe for, or treat the above described pet. I assume responsibility for all charges incurred in the care of the animal. I also understand that ALL PROFESSIONAL FEES ARE DUE AT TIME SERVICES ARE RENDERED.

I authorize my pet’s picture to be used for Clayton Animal Hospital or Clayton Animal Hospital media purposes. *

Signature of client responsible for pet(s) *

Clear Signature

Date *

Your veterinarian in Clayton, Ohio

We proudly serve the pets of Brookville, Clayton, Dayton, Englewood, Trotwood, Union, and beyond. We look forward to seeing you and your pet soon! You may book an appointment by clicking the button below.

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