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New Client Form
New Client Form
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New Client Information
Appointment Date
*
MM slash DD slash YYYY
Appointment Time
*
Hours
:
Minutes
AM
PM
AM/PM
Title (Mr. / Mrs. / Ms. / etc.)
*
First Name
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Last Name
*
Home Phone
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Work Phone
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Email Address
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Address
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Street Address
City
Alabama
Alaska
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Armed Forces Americas
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State
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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.
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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)
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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.
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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.
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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