New Client Form

Welcome! We are glad you are here, and we look forward to providing the very best care for you and your pet(s)! Please take a moment to share information about you and your pet(s).

If you prefer to print out this form, please download the PDF form here.

    Personal Information

    Your First Name:
    Your Last Name:
    Home/Cell Phone:
    (add **next to primary number)
    Address:
    (include City, State,Zip)
    Email:
    (Your email will only be used for notifications from Teller Park Veterinary Service)
    Spouse/Co-Owner Name:
    Spouse/Co-Owner Phone Number(s):
    Spouse/Co- Owner Email:
    How did you hear about us?
    Referral - Whom may we thank?

    Pet’(s) Information

    Pet #1

    Name:
    Type of Pet: DogCat
    Date of Birth or Approximate Age:
    Breed/Color/Markings:
    Sex: MaleFemale
    Neutered or spayed? YesNoUnsure
    Any ongoing health issues?

    Pet #2

    Name:
    Type of Pet: DogCat
    Date of Birth or Approximate Age:
    Breed/Color/Markings:
    Sex: MaleFemale
    Neutered or spayed? YesNoUnsure
    Any ongoing health issues?

    Pet #3

    Name:
    Type of Pet: DogCat
    Date of Birth or Approximate Age:
    Breed/Color/Markings:
    Sex: MaleFemale
    Neutered or spayed? YesNoUnsure
    Any ongoing health issues?
    Name/Number of Previous Veterinarian

    Due to state law and insurance requirements, all dogs and cats must be current on rabies vaccination. Vaccinations can be updated at the time of your appointment. All hospitalized patients must be current on vaccines to prevent the spread of infectious diseases.