ToMorrow's Veterinary Care

14110 Kenilworth Street
Waverly, NE 68462

(402)786-2600

waverlyvet.com

New Client Form

Owner(s) Information
Owner (required)
First Name (required)
Last Name (required)
Spouse/Other
First Name
Last Name
Address (required)
Street Address (required)
City (required)
,
State / Province (required)
Zip / Postal Code (required)
Home Phone (required)
Phone TypePhone Number (required)
Other Phone (required)
Phone TypePhone Number (required)
E-Mail Address :
Emergency Contact Information (required)

How would you like to receive vaccination reminders? (required)
Email
Postcard


Would you like a reminder call the day prior to scheduled appointments? (required)
Yes
No


Pet Information
Pet's Name (required)

Species (required)
Dog
Cat
Other


Breed (required)

Color (required)

Pet's Date of Birth or Age (required)

Gender (required)
Male
Male/Neutered
Female
Female/Spayed
Unsure


Do you plan to spay/neuter? (required)
Yes
No
Undecided


If not spayed or neutered, do you plan to breed your pet? (required)
Yes
No
Undecided
They are "fixed"


How long have you owned this pet? (required)

Where did you get him/her? (required)

Is your pet microchipped? (required)
Yes
No
No, but I am interested in more information about microchips


How much time is spent outdoors? (required)
Strictly outside
50/50
Every day briefly
Strictly inside


What brand of food does you pet eat? Canned, dry, or pouch? (required)

Does your pet get table scraps? If yes, what & how often? (required)

How do you view your pet in terms of overall health and wellness concerns/issues? (required)
He/she is a family member. I am concerned about all health issues/recommendations.
He/she is my pet. I want the healthy and pain free.
I'm not attached. Just the absolute essentials, please.


Other Information
Reason for visit (required)

Name of former veterinary practice (required)

May we request a transfer of records? (required)
Yes
No


Does your pet have a history of illness or medical concerns? If yes, please explain. (required)

Is your pet currently on heartworm preventative? (required)
Yes
No


Is your pet currently getting flea/tick control? (required)
Yes
No


Is your pet on any other medications? If yes, please list. (required)

Does your pet have any drug allergies? If yes, please list. (required)

How did you hear about us? If by a friend, please list their name so we can thank them. (required)

Please read:
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 service/release and that a deposit may be required in some instances.
I have read this statement and... (required)
I agree
I disagree



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