Willis Vet - New Client Form

1
Owner's Name
First Name
Last Name
2
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
3
Phone
Alternate Phone
Email
4
Spouse or Significant Other (First Name)
Spouse or Significant Other (Last Name)
Spouse or Significant Other (First Name)
Spouse or Significant Other (Last Name)
Phone
Alternate Phone
Email
5
How did you find out about us?(Mark ALL that apply)
Billboard
Kroger Grocery Cart
Drive By
Personal Recommendation
Internet Search / Website
Review It magazine - The Woodlands
Review It magazine - Lake Conroe
Saw us at an event
Facebook
6
Whom may we thank
7
What event?
8
FINANCIAL RESPONSIBILITY/ POSSESSORY LIEN* This field is required.
Stone Ridge Veterinary Medical Center I understand that I assume financial responsibility for all services rendered. I further agree to pick up my pet at the designated time and to pay in full all services rendered. I also understand that my pet will not be released until the balance is paid in full. If my pet is not picked up as agreed, a written notice of abandonment will be mailed to me. Twelve days after the notice is issued, my pet will be considered abandoned and may be disposed of in a manner deemed appropriate by Stone Ridge Veterinary Medical Center. By signing this document, I attest that I have read and agree to the aforementioned conditions
9
TREATMENT AUTHORIZATION* This field is required.
I understand that every effort will be made to achieve a successful outcome and to provide safe in-hospital care and handling. I hereby authorize this veterinary facility to receive, prescribe for, treat, or perform surgery upon the pet listed on the form with my consent. Furthermore, I agree to pay fees for services rendered at the time of service. I agree to pay for the costs of collection in the event that collection efforts become necessary. I understand that veterinary service is provided during nighttime hours only at the local emergency clinic. Continuous of qualified personnel during nighttime hours are not provided at this clinic.
10
ALL ANIMALS COMING INTO THE HOSPITAL MUST HAVE A CURRENT RABIES VACCINE. IF PROOF IS NOT PROVIDED A THE TIME OF VISIT, A RABIES VACCINE WILL BE GIVEN AT YOUR EXPENSE.

TO HELP PREVENT THE SPREAD OF INFECTIOUS DISEASE, ALL HOSPITALIZED, BOARDING, AND DROP OFF ANIMALS MUST BE CURRENT ON ALL VACCINATIONS AND FLEA FREE.

BY SIGNING THIS DOCUMENT, I ATTEST THAT I HAVE READ AND AGREE TO THE AFOREMENTIONED CONDITIONS.
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Signature
Clear
12
Pet(s) Information
Name of Pet
Pet’s DOB or Age
Dog
Cat
Species
Male
Female
Gender
Spayed
Neutered
Spayed / Neutered
Breed
Color
13
Give the date that the following vaccinations or procedures were last performed
List any previous surgeries your pet has had
List any previous or current illnesses
List any medications your pet is taking
List any allergies to medications or vaccines
List any special diets your pet is on
List any other information that you feel the doctor should know
List any other information that you feel the doctor should know
14
Please provide your previous Veterinarian's Information, so we may request your pet's records.
Previous Veterinary Office
Previous Veterinarian's Phone Number
Should be Empty:

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