Monday-Friday 7 AM to 7 PM
Saturday 9 AM to 5 PM
(281) 578-1506
20701 Kingsland Blvd. Suite 105,
Katy, Texas 77450
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New Client Form
Client Information
We keep all Client Information Confidential
Date
*
Date Format: MM slash DD slash YYYY
Owner Name
*
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Home Phone
Cell Phone
*
Work Phone
Email
*
In case of emergency and we cannot contact you, who should we contact?
*
Communication Consent – Do we have permission to contact you using one of the below communication methods? Choose all that apply.
*
Home Address
Email
Home Phone
Work Phone
Media Consent – I grant Kingsland Blvd Animal Clinic and its representatives/employees the right to take photographs of me and/or my pet, and to copyright, use and publish the same in print and/or electronically.
*
Select
Yes, I Consent
No, I do not Consent
How did you hear about us?
*
Select
Referral
Google
Facebook
Business Directory (Yelp, Nextdoor, Angie's List, Yellow Pages etc.)
Online Ad
Houston PetTalk Magazine
Print Ad
Community Newsletter
Community Event
Drive By
Other
If other, please explain. If referral, please let us know whom we can thank.
Pet Information
Name
*
Species
*
Species
Canine
Feline
Other
If Other, list species.
*
Breed
*
Color
*
Birthday/Age
*
Sex
*
Sex *
Male
Female
Spayed/Neutered
*
Spayed/Neutered *
Yes
No
Unknown
Known Allergies
*
Microchipped
*
Microchipped *
Yes
No
Microchip Number
Pet Food
*
Medications/Supplements
*
Should your pet be muzzled?
*
Should your pet be muzzled? *
Yes
No
Has your pet ever bitten anyone?
*
Has your pet ever bitten anyone? *
Yes
No
†We will need proof of vaccines for our records. ††We will request records.
Previous Veteriarian††
*
Dog Vaccines
For dogs, please confirm which vaccines are current for your pet.
Rabies Vaccine
Current
Not Current
I Don't Know
DHLPP Vaccine (The "Distemper Shot")
Current
Not Current
I Don't Know
Bordetella Vaccine
Current
Not Current
I Don't Know
Canine Influenza H3N8 Vaccine
Current
Not Current
I Don't Know
Leptospirosis Vaccine
Current
Not Current
I Don't Know
Cat Vaccines
For cats, please confirm which vaccines are current for your pet.
Rabies Vaccine
Current
Not Current
I Don't Know
FVRCP Vaccine
Current
Not Current
I Don't Know
Feline 2-FeLV (Protection against Feline Leukemia) Vaccine
Current
Not Current
I Don't Know
FIP (Feline Infectious Peritonitis) Vaccine
Current
Not Current
I Don't Know
Authorization
Permission to share your records with Other Hospitals/Emergency/Specialty.
*
Yes
No
Permission to share your records with Groomers/Daycare.
*
Yes
No
Permission to share your records with Pet Insurance.
*
Yes
No
Authorization
*
AUTHORIZATION: I, the undersigned, do hereby certify that I am the owner, or assuming responsibility, financial or otherwise, for the animal being presented to Kingsland Blvd Animal Clinic for the treatment of care. I hereby consent and authorize Kingsland Blvd Animal Clinic to receive, prescribe for or treat, as indicated, this animal presented. It is thoroughly understood that I assume all risks. All animals staying must be current on all vaccines and be free of external and internal parasites. We reserve the right to update vaccines and treat parasites as needed at the owner’s expense. I agree, if appropriate, to pick up this animal at the designated date and time agreed to by myself and Kingsland Blvd Animal Clinic. If in the event that the animal is not picked up, there will be a notice of 10-days to come claim the animal or it will be considered abandoned. The animal will be held in the manner that is considered to be most appropriate for the animal and the hospital. It is understood that I am not released from costs associated with the care of the pet. We do not bill and all fees are due when services are rendered. Deposits are required for all hospitalized patients. We accept debit cards, credit cards (Visa, Mastercard, Discover, American Express), checks, and cash. Our hospital accepts third-party payment plans, including CareCredit and Scratchpay. I understand that if I do not pay my balance in full, that I am responsible for all statement fees, finance charges, and attorney/collection fees.
Owner/Responsible Party
*
Date *
*
Date Format: MM slash DD slash YYYY
Name
This field is for validation purposes and should be left unchanged.