New Client Form Name* First Last Address* Street Address City State ZIP / Postal Code Preferred contact phone number*Email* Additional names on the account (please mark relation):How did you hear about us?Pet Information:NameAge/D.O.B.SpeciesBreedColorWeightSex:*Select OneMaleFemaleSpayed/Neutered?*Select OneYesNoDoes your pet have allergies?Has your pet ever had a reaction to vaccines or medication?YesNoIf yes, what happened?Has your pet had any major surgeries?Does your pet have any behavior problems/issues?List any foods and treats you give your pet:Are you interested in in-depth nutrition counseling for your pet?YesNoIf yes, we will send an additional survey to complete.Who is your pet’s regular veterinarian?I give consent for examination, diagnosis, and treatment of my pet by Dr. Tracy Duffner. I understand that all risks of testing and treatment and the various options available will be explained to me by Dr. Duffner. I understand that I can request an estimate for anticipated cost at any time. Client signature:Date NameThis field is for validation purposes and should be left unchanged.