Magalia Pet Hospital New Client Form

New Client Form

Client Information

* Indicates required field

Name *

First

Last

Client Date of Birth *

Your Employer (in case of emergency) *

Occupation *

Spouse or Co-Owner's Name *

Work Phone *

Spouse's Employer *

Occupation *

Work Phone *

Email *

Primary Phone Number *

Additional Phone Number *

Address Line 1 *

Address Line 2 *

City *

State *

Zip Code *

Whom May We Thank for Referring You? *

Person presenting the pet for treatment (If other than the owner)

Name *

First

Last

Relationship to Owner *

Address of Non-Owner *

City, State, Zip *

Name of current/previous Veterinarian *

May we contact this Veterinary Hospital for previous records *

Yes No

Any Additional Comments *

Statement of Ownership

By checking below, you certify that you are the owner/agent of the animal(s) listed above and that you also authorize the veterinarian to examine, prescribe, or treat the animal(s) above. You also certify that you will assume presponsibility for all charges the day that services are rendered.

Confirmation *

I agree

May we share images of your pet on our website/facebook page or printed materials? *

Yes No

Submit