Vitality Veterinary of Swansea
New Patient Form

573-5 GAR Highway Swansea, MA 02777

We know your pet’s health is important and we thank you for trusting us to care for them. To help us provide the best care possible, please take a few moments to fill out this form completely. Thank you!

First Name*

Last Name*

Physical Address*

City*

State*

Zip*

Phone Number*

Email Address*

Preferred Contact Method*

Your email address will only be used for our automatic reminder system that informs you when your pet’s vaccines, recheck appointments, and any other pertinent information regarding your pet, are due. This method will be used in lieu of reminder cards or phone calls.

Pet Name*

Emergency Contact Phone*

How did you learn about our clinic?*

If Recommended, by whom?

Reason for Visit?*

Do you have pet insurance*

If yes, which company & policy number?

Pet Breed*

Pet Color*

Birthday or Age*

Gender*

Is your pet spayed or neutered?*

Authorization

I hereby authorize the veterinarian to examine, prescribe for, and/or treat the above described pet. I assume full responsibility for all charges incurred for the care of this animal. I also understand that these charges will be paid at the time of release and that a deposit may be required for surgical treatment. I authorize Vitality Veterinary Services to use photographs of my pet for purposes of publicity, advertising, web content, and/or the Vitality Veterinary Services Facebook page.

I accept

Vitality Veterinary of Swansea New Patient Form

Authorization

Vitality Veterinary of Swansea
New Patient Form