New Client Form

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New Client Form

Please fill out this form as completely and accurately as possible so we can get to know you and your pet(s) before your visit.

Click here to download the new client form hard copy.

Owner Information

Client Name *

First

Last

Primary Phone *

Additional Owner *

First

Last

Additional Phone

Email *

Mailing Address *

Address Line 1

Address Line 2

City

State

Zip Code

Physical Address (if different from mailing address) *

Address Line 1

Address Line 2

City

State

Zip Code

How did you find out about our hospital? If you were referred by someone, who should we thank? *

Do you qualify for a Military discount? *

Are your tax exempt? *

What is your preferred method of contact: *

Phone Call
Test

Pet Information

Pet's Name *

Species (dog, cat, horse, other) *

Sex *

Male
Neutered Male
Female
Spayed Female

Age/Date of Birth *

Color *

Breed *

Does your pet have a microchip identification? *

What is the microchip number?

Date and location of last vaccinations *

Is your pet insured? *

If yes, what insurance *

Prior Illnesses *

If yes, please list *

Please list all current medications, including preventions

Any known allergies *

If yes, please list *

Do you have a second pet? *

Pet's Name *

Species (dog, cat, horse, other) *

Sex *

Male
Neutered Male
Female
Spayed Female

Age/Date of Birth *

Color *

Breed *

Does your pet have a microchip identification? *

What is the microchip number?

Date and location of last vaccinations *

Prior Illnesses *

If yes, please list *

Please list all current medications, including preventions

Any known allergies *

If yes, please list *

Do you have a third pet? *

Pet's Name *

Species (dog, cat, horse, other) *

Sex *

Male
Neutered Male
Female
Spayed Female

Age/Date of Birth *

Color *

Breed *

Does your pet have a microchip identification? *

What is the microchip number?

Date and location of last vaccinations *

Prior Illnesses *

If yes, please list *

Please list all current medications, including preventions

Any known allergies *

If yes, please list *

Do you have a fourth pet? *

Pet's Name *

Species (dog, cat, horse, other) *

Sex *

Male
Neutered Male
Female
Spayed Female

Age/Date of Birth *

Color *

Breed *

Does your pet have a microchip identification? *

What is the microchip number?

Date and location of last vaccinations *

Prior Illnesses *

If yes, please list *

Please list all current medications, including preventions

Any known allergies *

If yes, please list *

Do you have a fifth pet? *

Pet's Name *

Species (dog, cat, horse, other) *

Sex *

Male
Neutered Male
Female
Spayed Female

Age/Date of Birth *

Color *

Breed *

Does your pet have a microchip identification? *

What is the microchip number?

Date and location of last vaccinations *

Prior Illnesses *

If yes, please list *

Please list all current medications, including preventions

Any known allergies *

If yes, please list *

PAYMENT IS DUE AT TIME OF SERVICE WE DO NOT OFFER PAYMENT PLANS. We accept all major Credit Cards, Scratch Pay, Care Credit, Cash and Checks. There is a service fee of $30.00 for all returned checks. I, as authorized agent of the pet(s), authorize the veterinarian to examine, prescribe for, and/ or treat my pet(s). I allow Northside Veterinary Hospital (NSVH) to release my pet(s) information to other veterinary hospitals, boarding and grooming facilities unless I specifically notify NSVH not to release any information. *

I assume responsibility for all charges incurred in the care of my pet(s).

Digital Name of Responsible Party *

Date *

Phone

Download Our App and Connect with Us on PetDesk!

At Northside Veterinary Hospital in Shawnee, OK, we take veterinary medicine to the next level without sacrificing the family feel vital to quality patient care. Being attentive to your pet’s needs and understanding your concerns are extremely important to us. Request an appointment using our online system on PetDesk, and keep up with your pet’s health by downloading our app!

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Have Any Questions?

Get in touch! We look forward to hearing from you.

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Location

121 W 45th
Shawnee, OK 74804

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Contact Information

Phone: 405-273-3700
Fax: 405-273-3705
Email: northside@nsvhok.com

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Hours

Mon-Fri: 8:00 AM – 6:00 PM
Sat: 8:00 AM – 4:00 PM
Sun: Closed

Name *

First

Last

Email *

Phone

How can we help you? *

Website