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New Client Form

"*" indicates required fields

New Client Information

Appointment Date*

MM slash DD slash YYYY

Appointment Time*

Hours

Minutes

AM/PM

Title (Mr. / Mrs. / Ms. / etc.)*

First Name*

Last Name*

Phone*

Email Address*

Additional Owner's Name

Additional Owner's Phone

Address*

Street Address

City

State

ZIP Code

Pet 1 Information

Pet Name*

Species / Breed*

Color*

DOB / Age*

Sex*

Male

Female

Spay / Neuter / Intact?*

Spay

Neuter

Intact

Microchip #

Pet 2 Information

Pet #2 Name

Species / Breed

Color

DOB / Age

Sex

Male

Female

Spay / Neuter / Intact?

Spay

Neuter

Intact

Microchip #

Please provide your signature* as authorization to release/obtain vaccine information and medical records to or from other veterinary grooming or borading facilities.

Previous Animal Hospital

Please sign* here if you will allow Florda Wild Veterinary Hospital to use your pet's photo for our promotional purposes (website and social media)

Florida Wild Veterinary Hospital practices alternative medicine including acupuncture, herbs and homeopathic remedies. Although there is no FDA approval on these medications and scientific research has not proven its efficacy, we see great clinical success. Please sign* below if you will allow Florida Wild Veterinay Hospital to use such therapies to help heal your pet.

If not approved, please type “not approved.”

How did you hear about Florida Wild Veterinary Hospital. Check all that apply.*

Google Search / Reviews

Yahoo Search / Reviews

Yelp Search / Reviews

Facebook / Instagram

Daytona Beach News-Journal

Deland Beacon

Drive-By

Welcome to the Neighborhood Postcard

Natural Awakenings Magazine

Florida Wild Rescues

Client Referral

Another Vet Hospital

If you were referred, please share who it was so we can thank them!*

Please mark the 2 things that are most important to you when looking for a veterinarian.*

Efficiency – quick wait times

Well-educated Veterinarians

Warm and caring Veterinarians and Staff

Practice holistic medicine

Inexpensive services

What would you like to learn about most in the veterinary field?*

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What's Next

1
Call us or Schedule an Appointment Online
2
Meet With a Doctor for an Initial Exam
3
Put a Plan Together for Your Pet

Make An Appointment

Where family pets find loving care

Make An Appointment

(386)734-9899

115 E Euclid Ave,
DeLand, FL 32724

Home
About Us
Services
The Funky Mutt Market
- Hip Hangouts
Online Pharmacy
Resources
Contact Us

Monday

7:30am - 5:30pm

Tuesday

7:30am - 5:30pm

Wednesday

7:30am - 7:00pm

Thursday

7:30am - 5:30pm

Friday

7:30am - 5:30pm

Saturday

9:00am - 1:00pm

Sunday

Closed

New Client Form

New Client Information

Pet 1 Information

Pet 2 Information

What's Next

Call us or Schedule an Appointment Online

Meet With a Doctor for an Initial Exam

Put a Plan Together for Your Pet

Where family pets find loving care