New Client Form YOUR INFORMATION Name * First Name Last Name Drivers License Number Email * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Cell Phone * (###) ### #### Home Phone (###) ### #### Preferred Method of Contact * Phone Email Mail How did you hear about us? Google Word of Mouth (Friend or Family Referral) Drive By Social Media (Facebook, Instagram) YOUR PET'S INFORMATION Pet's Name * My Pet is a... * Dog Cat My Pet is: * Male Female My Pet is Spayed or Neutered. * Yes. No. My Pet's Previous Vet is... If applicable, we will reach out to your previous vet for records before your first visit. Pet's Date of Birth MM DD YYYY Pet's Age: * Pet's Breed: * Pet's Color: * Microchip Number: City License Number: Any Known Allergies? * List of Current Medications: * Reason for Visit: * CONSENT 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 for surgical treatment. Signature of Pet Owner or Person Responsible for Pet: * If completing digitally, please type your name. I hereby authorize Fayette Veterinary Clinic to use photos of my pet on social media such as Facebook, Instagram, Clinic Website, etc. * Yes No Date * MM DD YYYY Thank you for submitting our New Client Form. We have received it and look forward to meeting you! If you have any questions, please feel free to contact us by calling 859.272.4364 or emailing fayettevet144@gmail.com.