New Client Form

Welcome to North Torrington Veterinary Hospital! Our mission is to provide our clients and patients with the very best loving, compassionate health and wellness care from before hello to beyond good-bye. So that we may provide you with exceptional service, please share some information with us.

Are you a

New Client
Current Client with a New Pet

Date

Owner's Name *

First

Middle

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone

Cell Phone

Email *

Spouse or Co-Owner's Name

Phone

How did you first hear of us?

Recommendation
Website
Yellow Pages
Sign
Newspaper
Other

Whom may we thank for the recommendation?

If Other, please explain:

Pet Information

Pet's Name

Age and/or Date of Birth

Species

Dog
Cat
Other

If Other, please explain:

Breed

Sex

Male
Female
Neutered Male
Spayed Female

Date Neutered or Spayed:

Date Last Vaccination

Last Rabies Vaccination

Where Shots Obtained

Long-Term Problems (if any)

Reason For Visit:

Driver's License Number:

I hereby authorize the veterinarian to examine, prescribe for, or treat, the above described pet(s). I assume responsibility for all charges incurred in the care of this animal. I also understand that these charges will be paid at the time of release and that a deposit may be required for surgical treatment. *

I have read and understand

WE REQUIRE PAYMENT WHEN SERVICES ARE RENDERED - we do not offer payment plans. For your convenience, we accept MasterCard, Visa, Discover, AmEX, Care Credit, Scratch Pay, debit card, and cash. I verify that all the information provided is accurate. *

I have read and agree

Digital Signature *

Today's Date: *

Comment

Request an appointment online or through our PetDesk app.

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You can download the free PetDesk app through the app store. PetDesk gives you instant access to your pet's scheduled appointments, medications, and lab work.

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