New Client Form Client Name * First Name Last Name Email * Phone Number * (###) ### #### Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Pet Name List all pet's receiving services. Species Dog, Cat, Rabbit, Guinea Pig, etc. List all that apply Breed List all that apply Date of Birth List all that apply, approximate if unknown. Gender F= female SF = spayed female M = male NM = neutered male List all that apply Weight Approximation is fine. List all that apply Current Rabies Vaccine? Applies to dogs and cats over 4 months old. Pet's Veterinarian/Veterinary Clinic * Medications? Please list all. Are there any concerns you would like to discuss? I.e. lumps, bumps? Itchy pet? Overweight/underweight? Scooting/licking? Acting different? etc? How did you hear about us? Agree to Terms and Conditions? * As a registered veterinary technician, I legally can not diagnose or prognose any medical issues your pet may have. I can not prescribe any medications. I can not perform any surgical procedures. Proof of current rabies status required. I will accept a photo of your certificate or your veterinarian may email me at petnursingservices@gmail.com. Unless otherwise specified, my assistant and I will perform all procedures ourselves. For our own safety, my assistant and I must keep our gym shoes on while treating your pet. Disposable shoe covers eliminate our stability and traction, therefore decreasing the safety of ourselves and your pet. I may need to muzzle your pet. If your pet is too stressed or fearful, I may not be able to complete your request. We can discuss the available options to get your pet the services it needs. I retain the right to refuse service for any reason. Yes, I agree No, I do not agree Meow! Woof! Squeak! Translation: Thank you!
