Client Info Form | North Heart Vet

Date

Month

Day

Year

First name

Last name

Email

Phone

Address

Additional name/owner on Account?

Yes

No

If YES, is this person authorized to make medical decisions for your pet?

Yes

No

Does not apply, no other name on account

Preferred method of contact

Phone

Text

Email

PET 1 NAME

Age OR Date of Birth

Cat? Dog? Other?

Breed?

Color(s) and Identifying Marks?

Approximate weight if known

PET 2 NAME

Age OR Date of Birth

Cat? Dog? Other?

Breed?

Color or Identifying Marks

Approximate weight if known

More than 2 pets? Please fill out their info below.... Name, Age, Sex, Spayed/Neutered/Intact, Dog/Cat/?, Breed, Color, Weight.

I understand that payment is due at the time of services. I may request a treatment plan and discuss payment options prior to services being performed. North Heart Vet - Gwinn Sawyer accepts Cash, Credit and partnered payment plans (Care Credit, All Pet Card, Cherry, Scratch Pay, Varidi).

Our clinic requires dogs and cats to be current on their Rabies vaccine. If proof of vaccination cannot be provided, we will vaccinate at the doctor's discretion.

North Heart Vet Gwinn Sawyer may use photos/images as part of my pet's medical record. I consent to the use of these photos for social media, educational or training purposes as well.

Yes! Make my pet a star!

No thanks

Your Pet's medical records require YOUR consent to share with others (another vet clinic, an emergency vet, etc). We are unable to share without your permission.

Yes, I consent to sharing my pet's medical records if requested by another vet clinic.

I consent to sharing my pet's medical records with another clinic, but ONLY in an emergency situation.

No, do not share my pet's medical records without contacting me first.

If you are bringing your pet in for an exam, please also fill out the Patient Exam Info questionnaire as well.

New Client Information