New Client Form

Orchard Park Veterinary Medical Center

New Client Registration Form

If you are a new client, please complete this form and submit to us in advance of a scheduled appointment. This form should only be completed after you have already booked an appointment with us. The client services staff will provide you with a client identification # at that time.

This should help us expedite your registration and minimize your wait time. We ask all new client to provide us with a copy of your driver's license, so pleae make sure you have that with you when you arrive. For more information about what you will need to bring with you to appointments, please visit our Client Help Desk.

Thank you for your cooporation in letting us assist you.

Form - New Client

Name & Email (required)
First Name (required)	Last Name (required)

Address (required)
Street Address (required)


City (required)	State/Province (required)	Zip/Postal Code (required)
,

Client Identification #:

Daytime Phone (required)
Phone Type	Phone Number (required)

Evening Phone (required)
Phone Type	Phone Number (required)

E-Mail Address :

Pet's Name (required)

Age: Years, Months (required)

Type of Pet (required) :

Breed:

Sex: (required)
Male
Female

Neutered/Spayed
Neutered
Spayed

Are your pets vaccines current? :

Do you have your pet's medical records from another veterinary pratice?
Yes
No

Name of Former Veterinary Practice

May we request a transfer of records?
Yes
No

Reasons or conditions that prompted your visit?

Special requests or conditions?

Please list any additional pets here

Pet Treatment Authorization:

I verify that I have read the above statement and
I Agree
I Disagree

PAYMENT AGREEMENT:

I verify that I have read the above statement and
I Agree
I Disagree

Referral Policy Statement

Please read the below policy

I verify that I have read the above statement and
I Agree
I Disagree

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