New Client Information Form – White Rock Veterinary Hospital in Pflugerville, Texas

Appointment Date and Time

Date of appointment?*

Time of appointment?*

: HH

MM

Owner's Name and Information

Name*

First Last

Place of Employment

Driver's License

Address

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone*

Work Phone

Mobile Phone

Email*

Enter Email Confirm Email

Co-owner's Name & Contact #

Name

First Last

Phone

How did you find out about our practice?

If Other, please specify:

If Personal Referral, is there someone we can thank for this referral?

Name of most recent veterinary facility that you have taken your pet(s)?

Pet Information

How many pets are you filling out this form for?*

Pet's Name*

Species*

or if other species

Breed (if known)

Color

Date of Birth or Age (if known)

Special Identification (tattoo, microchip, etc.)

Sex

Is your pet on any medication or special diets?

Yes
No

If Yes, please list the medication or supplement

Is your pet on heartworm prevention?

Yes
No

If Yes, what type?

Is your pet on flea prevention?

Yes
No

If Yes, what type?

Any previous injury or serious illness?

Yes
No

If Yes, please list injury and/or serious illness

Please use the following box to give us any other relevant information about your pet

Pet's Name

Species

or if other species

Date of Birth or Age (if known)

Breed (if known)

Color

Special Identification (tattoo, microchip, etc.)

Sex

Is your pet on any medication or special diets?

Yes
No

If Yes, please list the medication or supplement

Is your pet on heartworm prevention?

Yes
No

If Yes, what type?

Is your pet on flea prevention?

Yes
No

If Yes, what type?

Any previous injury or serious illness?

Yes
No

If Yes, please list injury and/or serious illness

Is your pet on flea prevention?

Yes
No

Please use the following box to give us any other relevant information about your pet

Pet's Name

Species

or if other species

Breed (if known)

Color

Date of Birth or Age (if known)

Special Identification (tattoo, microchip, etc.)

Sex

Is your pet on any medication or special diets?

Yes
No

If Yes, please list the medication or supplement

Is your pet on heartworm prevention?

Yes
No

If Yes, what type?

Is your pet on flea prevention?

Yes
No

If Yes, what type?

Any previous injury or serious illness?

Yes
No

If Yes, please list injury and/or serious illness

Please use the following box to give us any other relevant information about your pet

Consent

I agree to the privacy policy.

White Rock Veterinary Hospital does not share your information with any other establishments or individual. The
information requested on this form is required to set up and maintain a file with White Rock Veterinary Hospital
For your convenience, we accept cash, personal checks, Visa, Master Card and Discover. Payment is expected at the time
services are performed. When more extensive care is necessary, financial arrangements can be made with our hospital
through Care Credit or Citi Health Card.
I also agree should it become necessary to forward my account for collection proceedings, in addition to the amount I
owe, I will also be responsible for the fees associated with the costs of collections.

Photo Release

Unless declined I understand that my pet's photo may be used on White Rock Veterinary Hospital's website and social media to help maintain, expand, and educate the public about our services.

I choose not to have my pet's picture shared.

Today's date:*

*There will be a $25.00 cancellation fee for any missed appointments without 24 hours prior notice.*

New Client Registration Form

Appointment Date and Time

Owner's Name and Information

Address

Co-owner's Name & Contact #

Pet Information

Section Break

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Location

Contact Us

Hours

Emergencies