Animal Veterinary Center

160 Bear-Christiana Road
Bear, DE 19701

(302)322-6488

animalvetcenter.com

New clients may complete our New Client Information Sheet to save time checking in.

Animal Veterinary Center

160 Bear-Christiana Road  Bear, DE 19701

Phone: (302) 322-6488    Fax: (302) 322-7666

www.animalvetcenter.com

 

  Dr. Renee Boggs     Dr. Teri Shultz

 

 

Client Information Sheet

 

                                                                                    Today's Date:    __________________

Client information

 

Client Name:     __________________________________________________________

 

Address:           ____________________________________                                   _

 

City__________                  _      State:             ____                Zip Code: __________       

 

Home Phone:   ________                                             Cell Phone:    __________________

 

Employer:  _________________________  Work Phone:     ____________________

 

Additional Name on Account:    _______________________________       

 

Additional Phone:  ______________________ 

 

E-mail address:  _______________________________________ (For Pet Portals access)

 

Social Security #:   ______________________     D.L. #:  ________________  State:  ______   

(Need both SS# & Driver's License# for check writing purposes.)

 

Patient Information

 

Patient:     _____________                                     Birthday:   _____________________________

 

Species:   ___________________________     Sex:          ______________________________

 

Breed:      ___________________________     Color:        ______________________________

 

 

How did you hear about us?

 

¨     Yellow Pages

¨     Newspaper

¨     Drive by

¨     Web Site

¨     Friend:  _____________________                    ¨   Updated  ________________