New Client Form in San Diego, CA | Kensington Veterinary Hospital

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Please complete this form to help us provide the best possible care and service. All information is kept strictly confidential.

1. Primary Client Information

Name(Required)

First Last

Email(Required)

Primary Phone(Required)

Country Phone Number

Phone Type(Required)

Cell

Home

Work

Secondary Phone

Country Phone Number

Phone Type

Cell

Home

Work

Address(Required)

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

2. Spouse / Partner / Secondary Client Information

Name

First Last

Phone

Country Phone Number

Phone Type

Cell

Home

Work

Authorized to make decisions/account changes?

Yes

3. Patient Information & Comfort

Name(Required)

Breed/Species(Required)

Age/DOB(Required)

Gender(Required)

Male

Female

Male Neutered

Female Spayed

Current Medications / Medical History:(Required)

Anxiety Assessment: Does your pet suffer from extreme fear, anxiety, or stress during veterinary visits?(Required)

Yes

Somewhat

Behavioral Presentation: If yes or somewhat, how is this anxiety typically exhibited? (Check all that apply)

Trembling/Shaking

Panting/Pacing

Hiding/Freezing

Growling/Hissing

Snapping/Biting

Urinating/Defecating

Requires Chemical/Oral Sedation

Other

Other Details(Required)

4. Previous Veterinary History

Previous Hospital/Clinic Name

Phone

Country Phone Number

Address

City State

May we contact them to request medical records?

Yes

5. Deposit, Cancellation & Policy Agreement

New Client Booking Deposit: To secure and finalize your initial appointment, pre-payment of the first examination fee ($104.60) is required. This deposit will be applied directly to your first visit.
Cancellation Policy: We require a minimum of 24 hours' notice for any appointment cancellations or rescheduling requests. Failure to provide 24 hours' notice, or missing a scheduled appointment, will result in the forfeiture of your examination deposit (or a cancellation fee equal to the cost of the standard examination).

By signing below, I acknowledge that I have read, understood, and agree to the policies stated above.

Signature(Required)

Date(Required)

New Client Form

1. Primary Client Information

2. Spouse / Partner / Secondary Client Information

3. Patient Information & Comfort

4. Previous Veterinary History

5. Deposit, Cancellation & Policy Agreement

Affiliations

Location

Office Hours

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New Client Form

1. Primary Client Information

2. Spouse / Partner / Secondary Client Information

3. Patient Information & Comfort

4. Previous Veterinary History

5. Deposit, Cancellation & Policy Agreement

Affiliations

This site uses tracking technologies

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