New Patient Form

    Patient and Client Information

    How you became aware of our clinic:

    Owner/Caretaker:
    Cell:
    Co-owner/ Caretaker:
    Cell:
    Children:
    Address:
    PO Box:
    City:
    State:
    Zip:
    Residence Phone:
    E-mail address

    KVC, P.C. will use this only for reminders, newsletters, and office communications. (We do not give out e-mail addresses to third parties, other than our reminder system).

    Place of employment of owner :
    Phone:
    Place of employment of co-owner:
    Phone:
    If necessary, may we call you at work?:
    Best time to call:
    When is the best time to reach you at home?:



    So that we are able to suit your individual needs, which do you feel most applies to you

    Check One

    Check One

    Check One



    My Pets:


    Pet:

    Name:

    Sex:
    Altered: Birth date or Age: Breed:


    Pet:

    Name:

    Sex:
    Altered: Birth date or Age: Breed:


    Pet:

    Name:

    Sex:
    Altered: Birth date or Age: Breed:


    Would you like us to keep you informed about procedures that may lengthen the life of your pet?:

    Do your pets have any known allergies?

    What prior illnesses or surgeries should we know about?

    Is your pet currently on a special diet or medication?

    Are any of the following a concern to you about your pet(s)?

    For your convenience we can provide reminders for when vaccinations or procedures are needed. If you are transferring the care of your pets to our office, we can create reminders for you. If you would like us to acquire copies of your records, please sign below.

    I give permission to transfer my pets’ records from to the Kalona Veterinary Clinic, P.C.

    REQUIRED – PLEASE COMPLETE THE FOLLOWING

    We accept MasterCard / Visa, Discover, Cash or Check, and Debit Cards. Unless prior arrangements have been made, accounts must be paid in full at the time that services are rendered. For certain procedures, we may request that some amount be paid before the procedures are completed. If you would like a written estimate, we would be glad to provide one for you.

    The person(s) responsible for paying this account is/are

    My preferred method of payment is