If you already have an appointment, what is your scheduled appointment date? If you do not have an appointment, please call our clinic at (515) 987-4552 to schedule before filling out this form.

Appointment Date(Required)

Client Information

First Name(Required)

Last Name(Required)

Address(Required)

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Primary Number Type(Required)

Cell

Home

Work

Primary Number(Required)

Secondary Number Type(Required)

Cell

Home

Work

Secondary Number(Required)

Email(Required)

Secondary Owner

First Name

Last Name

Relationship to Primary Owner

Secondary Owner Number Type

Cell

Home

Work

Secondary Owner Number

How did you hear about us?(Required)

Saw sign/drove by

Clinic website

Google/search engine

Facebook

Friend

Veterinarian

Who can we thank for the referral?(Required)

Additional parties Authorized To Act as Owner on your behalf for your pet. Please note whomever you list has your full permission to make decisions, medical or otherwise, for your pet.

1) Name

1) Phone Number

2) Name

2) Phone Number

3) Name

3) Phone Number

Patient Information

Name(Required)

Species(Required)

Breed(Required)

Color(Required)

Date of Birth: MM/DD/YYYY(Required)

Date of birth is estimated/unknown?(Required)

Yes

Sex(Required)

Where did you get this pet?

How long have you had this pet?

Having a history of our patients is very helpful for our doctors. Please provide information about your pet's previous medical history. If this is their first visit to any veterinary hospital, please type "NONE"(Required)

Previous Hospital Name(Required)

Please upload any previous records or files on your pet here:

Max. file size: 50 MB.

Do you have an additional pet to include?(Required)

Yes

2) Patient Information

Name(Required)

Species(Required)

Breed(Required)

Color(Required)

Date of birth is estimated/unknown?(Required)

Yes

Date of Birth: MM/DD/YYYY(Required)

Sex(Required)

Where did you get this pet?

How long have you had this pet?

Having a history of our patients is very helpful for our doctors. Please provide information about your pet's previous Animal Hospital. If this is their first visit to any hospital, please type "NONE"(Required)

Previous Hospital Name(Required)

Please upload any previous records or files on your pet here:

Max. file size: 50 MB.

Do you have an additional pet to include?(Required)

Yes

3) Patient Information

Name(Required)

Species(Required)

Breed(Required)

Date of Birth: MM/DD/YYYY(Required)

Color(Required)

Date of birth is estimated/unknown?(Required)

Yes

Sex(Required)

Where did you get this pet?

How long have you had this pet?

Previous Hospital Name(Required)

Please upload any previous records or files on your pet here:

Max. file size: 50 MB.

Do you have an additional pet to include?(Required)

Yes

4) Patient Information

Name(Required)

Species(Required)

Breed(Required)

Color(Required)

Date of birth is estimated/unknown?(Required)

Yes

Date of Birth: MM/DD/YYYY(Required)

Sex(Required)

Where did you get this pet?

How long have you had this pet?

Previous Hospital Name(Required)

Please upload any previous records or files on your pet here:

Max. file size: 50 MB.

Client Authorization

I give permission to Waukee-Clive to take pictures of my pet and potentially post them on social media or their website.(Required)

Decline

I authorize treatment and/or service for any animal I bring to Waukee-Clive Veterinary Clinic. I agree to pay for all charges at the time services are rendered for my pet(s). I certify that I am the primary owner of the pet(s) listed in this form. I authorize that the secondary owner has the authorization to sign for any treatment(s) and settle any balance for my pet(s). I will inform Waukee-Clive Veterinary Clinic of any abnormal symptoms my pet(s) may be having at the time of check-in at each appointment. I understand that the staff of Waukee-Clive Veterinary will put my pets’ health first and foremost and that in the incident a medical-related reaction or incident occurs, I do not hold Waukee-Clive Veterinary responsible. I have read and understood all the above provisions of the Client Agreement with Waukee-Clive Veterinary Clinic.(Required)

Thank you for entrusting your pet’s care to our care!

Dr. Jamie Bunn, Dr. Kristin Young, Dr. Holly Dolphin-Rooney, Dr. Kealie Mancino, Dr. Rachel Olesen, Dr. Adrienne Hufferd, and the entire staff at Waukee-Clive Veterinary Clinic!

Comments

This field is for validation purposes and should be left unchanged.

New Client – New Patient Form

Client Information

Secondary Owner

Patient Information

2) Patient Information

3) Patient Information

4) Patient Information

Client Authorization