New Client Registration Forms

Owner Information

First Name *

Last Name *

Email Address *

Phone Number *

Street Address *

City *

State *

Zip *

Emergency Contact

Contact Name *

Contact Phone *

How did you hear about us?

Pet Information

Pet's Name *

Species *

Breed *

Color/Markings

Date of Birth (or approximate age) *

Sex *

Weight (lbs)

Microchip Number

Current Diet / Food Brand

Any current concerns or issues?

Medical History

Previous Veterinarian / Clinic Name

Previous Vet Phone (for records transfer)

Is your pet currently on any medications?

Yes No

Current Medications & Supplements

Any known allergies?

Yes No

If yes, please describe

Has your pet had any surgeries?

Yes No

If yes, please describe

Date of Last Vaccinations

Current flea/tick/heartworm prevention?

Yes No

Anything else we should know?

I authorize Clix Family Hospitals to provide veterinary care for my pet. I understand that I am financially responsible for all charges. I have provided accurate information to the best of my knowledge. *

Preventive Care

Medical & Diagnostics

Surgery & Emergency

Additional Services

Forms Submitted Successfully!

Owner Information

Emergency Contact

Pet Information

Medical History

Questions About Registration?