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Call/Text: (650) 583-1500
[email protected]

Home
Services
About us
Resources
Contact

New Client Form

Home

New Client Form

New Client Form

Please fill out this form as completely and accurately as possible so we can get to know you and your pet(s) before your visit.

Name

First*

Last*

Partner/Another owner's Name

First

Last

Primary Phone *

Secondary Phone

Home Phone

*To provide you with better and more convenient communications, you consent to be contacted via text messages.

Email *

Physical Address*

Unit

City

State

Zip

Owner’s date of birth *

*We do not accept checks

Pet's information

#1 Pet Name*

Pets Age or Date of Birth

Breed*

Color*

Sex

Male Female Neutered Spayed

Species*

Weight

Micro-chipped

Yes No

Pet Insurance, if any

Does your pet have any food allergies?

Yes No

Medication Allergies?

Yes No

Does your pet have any past or present injuries or health concerns?

Yes No

Are vaccinations up to date? *

Please list previous veterinarian (if applicable).

Please upload any medical records for your pet(s)

My pet becomes unfriendly when:

Grabbed by collar Cage aggressive Touched on mouth Friendly Hugged Touched on ears Touched while sleeping Around other dogs Touched on paws/tail Removed from furniture

Would you like to add information for a second pet?

Yes No

I consent and authorize Millbrae Pet Hospital to take my pet(s) photos andpost it on their social media.

I consent I DO NOT consent

I certify that I am at least 18 years old and I own the above-described pet and I do hereby consent and authorize the Millbrae Pet Hospital doctors and staff to admit my pet into the hospital while I am not present and to examine, administer vaccinations, and medications necessary for the health, safety, or well-being of the above pet while it is under their care and supervision, as agreed upon by me.

I consent I DO NOT Concent

Date / Time

Signature

Thank you. Your submission has been sent.

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LOCATION

128 Park Place
Millbrae, CA 94030

PHONE

650-583-1500

FAX

650-871-7160

EMAIL

[email protected]

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