Silver Maple Veterinary Clinic, Inc.
14993 Kutztown Road, Kutztown PA 19530
610-683-7988
New Client Form
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Client Name:
Please complete all information for each pet:
Pet #1
Pet #2
Pet #3
Name
Species (cat, dog, other)
Breed
Description (color)
Age
Date of Birth
(00/00/00)
Sex
M
F
M
F
M
F
Neutered or Spayed
Yes
No
Yes
No
Yes
No
Diet (kind of pet food)
Hrs. Spent Outside/Day
Vaccination & Lab History
(Dates Last Given) (00/00/00)
(Dog) DHLPPC
Yes
Yes
Yes
(Dog) Bordetella
Yes
Yes
Yes
(Dog) Lyme
Yes
Yes
Yes
(Dog) Rabies
Yes
Yes
Yes
(Dog/Cat) Heartworm Test
Yes
Yes
Yes
(Dog/Cat) Heartworm Prevention
Yes
Yes
Yes
(Dog/Cat) Stool Check
Yes
Yes
Yes
(Cat) FVRCP
Yes
Yes
Yes
(Cat) Leukemia
Yes
Yes
Yes
(Cat) Feline Leukemia Test
Yes
Yes
Yes
(Cat) Rabies
Yes
Yes
Yes
(Cat) FIP
Yes
Yes
Yes
(Cat) FIV
Yes
Yes
Yes
(Cat) Feline Aids Test
Yes
Yes
Yes
Previous Veterinarian or Hospital for vaccination/medical history on your pet(s):
Name
Phone
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