New Client Form

Welcome to Wimberley Veterinary Clinic! Fill out this form before your pet’s first visit to help us get to know you and provide the best care possible.

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New Patient Information Form

Owner Information

by of please

Owner's Name *

First

Last

Email *

Phone *

Mailing Address *

Address Line 1

Address Line 2

City

State

Zip Code

Place of Employment

Work Phone

Co-Owner Information

Co-Owner's Name

First

Last

Co-Owner's Phone

Co-Owner's Work Phone

Pet Information

Patient Name *

Age/DOB *

Breed *

Color *

Sex *

Spayed/Neutered *

When was your pet last vaccinated? *

Is your pet on heartworm preventative?

Does your pet have any existing medical conditions?

Is your pet on any medication? If so, please list:

Additional Information

Regular/Past Veterinarian's Name: *

Vet Phone

Must Have Proof of Current Rabies Certificate (Rabies tags DO NOT count as proof) If you cannot provide proof of rabies certificate, your pet will be given the vaccine and you will be charged $22. All animals over 12 weeks are required by law to be up to date on rabies:

Reason for Visit: *

Referred By:

In some cases a deposit may be required. Please indicate method of payment:

24-hour notice needed for any appointment cancellations.
All fees due upon patient release.
Any unpaid balance is subject to a monthly finance charge of 2.5% on any account 30 days past due. Accounts will be turned over for collection after 90 days past due, and may incur additional fees from the collection agency.

By clicking this box, I agree that Wimberley Veterinary Clinic has my permission to use any photograph of my animal(s) or myself with or without my name for any lawful purpose including but not limited to publicity, advertising, illustration and web content: *

By clicking this box, I agree that Wimberley Veterinary Clinic has my permission to use any photograph of my animal(s) or myself with or without my name for any lawful purpose including but not limited to publicity, advertising, illustration and web content

I accept the conditions outlined in this Information Form: *

I accept the conditions outlined in this Information Form

Signature *

Clear Signature

Today's Date *

*This promotion is valid for new clients only and may be used once per client. Cannot be combined with other offers or promotions. Other restrictions may apply.

New Client Form

New Patient Information Form

Owner Information

Co-Owner Information

Pet Information

Additional Information

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