Owner's Name

Name*

First Last

Address*

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

Date of Birth*

Day-Time Phone*

Evening 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?

Please use this area to give us any other relevant information about yourself or your family

Pet Information

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

Previous Veterinary Practice (if any)*

Previous Veterinarian (if any)

What vaccines were given at this time

Is your pet on any medication or supplement?

Yes
No

If Yes, please list the medication or supplement

Does your pet have allergies or drug reactions?

Yes
No

If Yes, please list the allergies and reactions

Are there any current or past medical conditions of which we should be aware?

Yes
No

If Yes, please comment on the condition(s) and indicate if they are current or past conditions

Would you like to add another pet?

Yes
No

Pet #2

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

Previous Veterinary Practice (if any)*

Previous Veterinarian (if any)

What vaccines were given at this time?

Is your pet on any medication or supplement?

Yes
No

If Yes, please list the medication or supplement

Does your pet have allergies or drug reactions?

Yes
No

If Yes, please list the allergies and reactions

Are there any current or past medical conditions of which we should be aware?

Yes
No

If Yes, please comment on the condition(s) and indicate if they are current or past conditions

Would you like to add another pet?

Yes
No

Pet #3

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

Previous Veterinary Practice (if any)*

Previous Veterinarian (if any)

What vaccines were given at this time?

Is your pet on any medication or supplement?

Yes
No

If Yes, please list the medication or supplement

Does your pet have allergies or drug reactions?

Yes
No

If Yes, please list the allergies and reactions

Are there any current or past medical conditions of which we should be aware?

Yes
No

If Yes, please comment on the condition(s) and indicate if they are current or past conditions

Cancellation / Missed Appointments Policy*

We at Foxfield enjoy seeing our clients, but we would like to remind you that we set aside your appointment time just for you! However, when you fail to show up for your appointment or cancel last minute, you are preventing other pets from being able to receive care. Therefore, we feel the need to put a new policy in place. We do understand that things happen in life and that is why we are flexible with first time cancellation issues.
-Appointment No Show / No Call will be assessed a $25 fee
-First cancellation with less than 24 hours notice, we understand things happen in life and offer flexibility with this first time cancellation issue.
-2nd and 3rd cancellation with under 24 hours notice for a regular appointment $25 each offense, same day cancellation of a surgery $50.
-After the 3rd time within in a 1 year period you will be asked to leave the practice.

First Last

Appointment Date and Time*

Appointment Date and Time

Appointment Date Time

Signature*

By entering your name below, I agree to pay in full for all treatments provided to my pet(s) by Foxfield Veterinary Services. I understand that all fees are due at the time of service. Any charges left unpaid will be sent to collections.

First Last

Date

New Client Registration Form

Owner's Name

Co-owner's Name & Contact #

Pet Information

Pet #2

Pet #3

Contact Us

Address

Contact

Hours