New Client Questionnaire - Sewickley Veterinary Hospital - Veterinarians serving Sewickley, PA

Sewickley Veterinary Hospital

1104 Ohio River Blvd.
Sewickley, PA 15143

(412)741-5550

sewickleyvet.com

New Client Questionnaire

New Client Questionnaire Form

Client Name (required)
First Name (required)
Last Name (required)
Spouses Name
First Name
Last Name
Street Address (required)
Street Address (required)
City (required)
,		State / Province (required)
Zip / Postal Code (required)
Cell Phone (required)
Phone TypePhone Number (required)
Home Phone
Phone TypePhone Number
E-Mail Address (required) :
How do you prefer we contact you (Select 2) (required)
mail
phone
email
text
How did you hear about us? (Friend, Drive by, Mailer, Online) (required)

If referred by a friend, please let us know who to thank

Previous Veterinarian and Phone

Do we have permission to contact your previous vet? (required)

Yes
No


Pet's Name

Species (required)

Dog
Cat


Color

Age

Breed

Sex (required)

Male
Female


Neutered/Spayed (required)

Yes
No


Previous Medical History/Concerns (required)


Second Pet (Optional)
Pet's Name

Species

Dog
Cat


Color

Age

Breed

Sex

Male
Female


Neutered/Spayed

Yes
No


Previous Medical History/Concerns

Do we have permission to contact your previous vet?

Yes
No



I understand that this is not a 24-hour veterinary hospital. Current business hours are posted & may be changed. There may be times the business is open, but no doctor is available/on-site.

I understand that FULL PAYMENT IS DUE AT THE TIME SERVICE IS RENDERED and that a 50% DEPOSIT MAY BE REQUIRED FOR ANY HOSPITALIZED PET or SURGERY. All unpaid balances are subject to a 1.5% per month interest charge. Returned checks are subject to the incurred returned check fee. In the event legal action is required to recover an unpaid balance I agree to pay all interest, court costs and attorney’s fees. I authorize the release of my pets’ medical records to Sewickley Veterinary Hospital.
Have you read and agree to the above statements? (required)

Yes
No


Today's Date (required) :
Please type your full name below: (required)


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