New Client Form | Pharr Road Animal Hospital

New Client Form

1 Client Information

2 Other persons authorized to make decisions about your pet

3 Pet Information

4 Authorization

Client Information
Please enter some general information
Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Primary Phone*
Cell Phone
Work Phone
Email*
Enter Email Confirm Email

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Other persons authorized to make decisions about your pet's care:
Name
First Last
Phone
Name
First Last
Phone

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Pet Information
Name*
Approx. Age*
Please enter a value between 0 and 100.
Birthday
Species*
- Canine
- Feline
Sex*
- Male
- Female
Spayed or Neutered?*
- Yes
- No
Breed*
Colors / Markings*
Last Vaccination performed at*
Current Medications*
Current Diet*
Current Heartworm Prevention*
Current Flea Preventative*
Medical Records
Drop files here or

Accepted file types: jpg, gif, png, pdf.

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How did you hear about us?
Which online review site did you use?
Which social media site were you referred from?
Which Website were you referred from?
Please tell us your friend's name so that we can thank them
Authorization*
- I Agree
I hereby authorize the veterinarians at Pharr Road Animal Hospital to examine, prescribe for and perform treatment on the aforementioned animal. I assume responsibility for any charges accrued during treatment of said animal and understand that payment for all charges and fees are due at the time services are rendered.

For appointments cancelled with less than twenty four hours notice or failed appointments, there may be a charge equal to the cost of a Physical Exam.

If you arrive more than 15 minutes late, we may reschedule your appointment or see you as a walk-in. A walk-in appointment will see the first available doctor and is subject to an additional fee. We strongly encourage all of our clients to arrive at least 10 minutes early fora scheduled appointment.
Name
This field is for validation purposes and should be left unchanged.

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New Client

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