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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*

Home Phone*

Work Phone

Cell Phone

Email Address*

Address*

Street Address

City

State

ZIP Code

Additional Owner's Name

Relationship to Primary Owner

Additional Owner's Phone

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 #

Pet 3 Information

Pet #3 Name

Species / Breed

Color

DOB / Age

Sex

Male

Female

Spay / Neuter / Intact?

Spay

Neuter

Intact

Microchip #

Pet 4 Information

Pet #4 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 boarding 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)

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

Our policy is full payment due when services are rendered. We accept Visa, MasterCard and Care Credit. Please direct any inquiries about your account to the Accounts Manager who will be most happy to assist you. Care Credit is great to have for emergencies with low to no interest fees. We do not accept cash or checks.*

If you are not able to keep an appointment, please phone our office 24 hours in advance (or at your first opportunity). This will enable us to help you with another appointment and to fill your slot with another patient in need. There will be a $35 fee assessed to your account if less than 24 hour notice is provided for appointments. We ask that you provide us with a 48 hour notice if you need to cancel or reschedule a procedure or surgery. A $100 fee will be charged if less than 48 hour notice is given.*

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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

Pet 3 Information

Pet 4 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