New Clients Form New Clients Form Client InformationName* First Last Spouse First Last Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Primary Phone*Spouse PhoneEmployer*If necessary, may we contact you at work?* Yes No Fax Number, if applicableEmail Address* Providing us with your email address will allow us to communicate with you in the event that we cannot reach you by telephone. Also, you will be able to access your pet portal through our website! There, you will be able to access your pet’s health information, access our online pharmacy, request appointments, received reminders, and more!How did you hear about us? Who/what may we thank for referring you?*What is your preferred method of being contacted?* Email Phone call Text Patient InformationPatient Name* First Last Species*Breed*Date of birth*Sex* Male Female Spayed Neutered Color*Is your pet on heartworm prevention?* Yes No What type/brand:*Is your pet on flea prevention?* Yes No What type/brand:*Has your pet been tested for viruses?* Yes No What was the test date and results?*Are there any other pets in your household?* Yes No How many and what species?*Previous medical records can be obtained from:Would you allow us to release immunization records to boarding kennels and grooming facilities?* Yes No Would you allow us to release your name, address and phone number(s) to someone who has found your lost pet(s)?* Yes No Do you grant Artemis Veterinary permission to use photos/videos of your pet on social media and/or for promotional purposes?* Yes No Do you have pet insurance? Ask us how we can help you submit your claims!* Yes No By signing below, you agree to our financial and payment policies:Signature*CAPTCHA Δ
