New Client Form

Co-Owner Name (first & last):

Co-Owner Phone Number:

Pet's Name

Age / DOB

Species

Breed

Color/Markings

Sex

Female Intact

Female Spayed

Male Intact

Male Neutered

Pet's Name

Age/DOB

Species

Breed

Color/Markings

Sex

Female Intact

Female Spayed

Male Intact

Male Neutered

We ask that you reach out to all previous veterinary hospitals where your pet has received care to request their medical records. This includes emergency and specialty hospitals. These records can be emailed to PolandAH@yourvetdoc.com or faxed to 207-998-8149. Having this information is essential for us to provide the best care for your pet. Please list each provider below so we know where to expect records from.

Veterinarian/Hospital Name:
City/State:
Veterinarian/Hospital Name:
City/State:
Veterinarian/Hospital Name:
City/State:
Veterinarian/Hospital Name:
City/State:

How did you hear about us?

Internet Search

Drive By/Sign

Client Referral

Other

If you were referred by a client, what is their name?

I understand that my pet’s picture may be used on social media sites.

YES, you can use my pet's photo.

NO, do not use my pet's photo.

New Client Form

Co-Owner Name (first & last):

Co-Owner Phone Number:

Patient Information:

Pet's Name

Age / DOB

Species

Breed

Color/Markings

Sex

Pet's Name

Age/DOB

Species

Breed

Color/Markings

Sex

Previous Medical History

How did you hear about us?

If you were referred by a client, what is their name?

I understand that my pet’s picture may be used on social media sites.

Reason for your pet's visit: