St. Francis Animal Hospital

15708 Gale Ave
Hacienda Heights, CA 91745

(626)968-4709

www.sfahospital.com

New Client Check In

Please make an appointment prior to filling out this form.

Thank you for your cooperation in letting us assist you.

New Client/ New Pet

Name (required)
First Name (required)
Last Name (required)
Spouse's Name
First Name
Last Name
Address (required)
Street Address (required)
City (required)
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State / Province (required)
Zip / Postal Code (required)
Primary Number (required)
Phone TypePhone Number (required)
Cell Phone Number (required)
Phone TypePhone Number (required)
E-Mail Address (required) :
Owner's Date of Birth (required) :
Pet's Name (required)

Pet's Birth Date (or Estimated Age)

Type of Pet (required) :
Breed: (required)

Pet's Color

Sex: (required)

Male
Female


Is your pet Spayed or Neutered?

Yes
No


Are your pet's vaccines current? (required)

Yes
No
I Don't Know


Does your pet have any allergies? (required)

Yes
No


Reasons or conditions that prompted your visit?

Special requests or conditions?

AUTHORIZATION
I hereby authorize the veterinarian to examine, prescribe for, or treat my pet. I assume all 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 of this animal and that a deposit may be required for surgical treatment.
ALL FEES ARE DUE AND PAYABLE UPON COMPLETION OF SERVICES.
By checking this box, you agree to the terms above. Please type your electronic signature below.
ELECTRONIC SIGNATURE
First Name
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