Smith Flat Animal Hospital

2012 Smith Flat Rd.
Placerville, CA 95667

(530)626-8180

smithflatanimalhospital.com

New Client Check-In

If you would like to make an appointment, you can assist us to expedite your check-in by submitting this form.

Thank you for your cooporation in letting us assist you.

New Client

Owner's Name (required)
First Name (required)
Last Name (required)
Physical Address (required)
Street Address (required)
City (required)
,
State / Province (required)
Zip / Postal Code (required)
Mailing Address (if different from above)
Street Address
City
,
State / Province
Zip / Postal Code
Daytime Phone (required)
Phone TypePhone Number (required)
Evening Phone (required)
Phone TypePhone Number (required)
E-Mail Address :
Pet's Name (required)

Age: Years, Months (or pet's date of birth - mm/dd/yy)

Type of Pet (required) :
Breed: (required)

Sex: (required)
Male
Female


Neutered/Spayed
Neutered
Spayed
Intact


Are your pet's vaccines current?
yes
no
I don't know


Does your animal have a microchip? If so, do you know the ID number?

Do you have your pet's medical records?
yes
no


Medical records at another veterinary Practice?
Yes
No


Name of Former Veterinary Practice

May we request a transfer of records?
Yes
No


Reasons or conditions that prompted your visit?

Previous medical problems or conditions?

What color is your pet?

How did you hear about our business?
phone book
internet
referral
other


Name of referrer

Employer (optional)

Driver's License Number (only needed if paying with personal check)

Expiration date

Payment is due when services are rendered

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