New Client Form – Companion Pet Care of Littleton

Thank you for choosing Companion Pet Care to care for your pet(s). Our team devoted to staying on top of the latest diagnostics, treatments, and wellness programs to maintain your pet's optimal health. Let's work together to keep your beloved furry friend happy and healthy. Please complete the information below so that we can ensure accurate record keeping and can better serve you. Search Companion Pet Care NH in your app store to download our app!

Owner's Information

Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Preferred Phone Number*

Alternate Phone Number

Email*

Enter Email Confirm Email

Place of Employment

Work Phone Number

Co-owner's Information

Name

First Last

Phone

Email

Pet(s) Information

Pet's Name*

Breed (if known)

Color

Date of Birth or Estimated Age

Sex

What food does your pet eat?

Is your pet on any medications, supplements, or flea/tick/heartworm preventatives?

Yes
No

If yes, please list the medications, supplements, or flea/tick/heartworm preventatives, including strength and how often your pet receives it.

Does your pet have allergies or drug reactions?

Yes
No

If Yes, please list the allergies and reactions

Are there any current or past medical conditions of which we should be aware?

Yes
No

If Yes, please comment on the condition(s) and indicate if they are current or past conditions

Do You Have Pet Insurance

Yes
No

Pet Insurance Provider

Additional Pet Information

Pet's Name

Breed (if known)

Color

Date of Birth or Estimated Age

Sex

What food does your pet eat?

Is your pet on any medications, supplements, or flea/tick/heartworm preventatives?

Yes
No

If yes, please list the medications, supplements, or flea/tick/heartworm preventatives, including strength and how often your pet receives it.

Does your pet have allergies or drug reactions?

Yes
No

If Yes, please list the allergies and reactions

Are there any current or past medical conditions of which we should be aware?

Yes
No

If Yes, please comment on the condition(s) and indicate if they are current or past conditions

Do You Have Pet Insurance

Yes
No

Pet Insurance Provider

Previous Veterinarian

Name

Previous Veterinarian Phone Number

Records: If you did not bring your pet's previous records, please have them faxed or emailed. Important information includes previous vaccine history, serious surgeries, chronic illnesses, recurrent prescriptions, and lab work. Your consent at the end of this form gives us permission to collect any records from your previous veterinarian.

Social Media Waver: We love the time spent with our patients. We are proud of the relationship we have with them and the care we provide. We would love the opportunity to share pictures and stories of your pets on our social media pages. Please check one of the options below:*

I decline to have pictures taken and shared on social media
I want to be asked permission prior to pictures being shared on social media
I give permission to share pictures and stories of my pets, you don't need to ask first

Is it okay if we offer your pet treats while here? ***WE UTILIZE PEANUT BUTTER AS A TREAT***

Yes
No

Payment Agreement: I understand that all fees must be paid at the time services are rendered. In the event the account is turned over for collection, I agree to pay collection fees and interest.*

Please Type Name Here

Date*

New Client Registration Form

Owner's Information

Co-owner's Information

Pet(s) Information

Additional Pet Information

Contact Us

Hours of Operation