New Client Information Sheet


Owner Information

Title:
Last Name: First Name: Middle Initial:
Address: Apt:
City: State: Zip Code:
Email:
Primary Phone: Secondary Phone:
Additional Phone:
Employer: Occupation:
Spouse/Alternate Contact: Contact Number:
How did you hear about us?:

 

Personal Information

Pets Unlimited is required by law to submit Date of Birth information (DOB) to the Department of Justice in order to dispense certain medications.

Social Security Number: Date of Birth:
Driver’s License Number: License State:

 

Record Transfer

 

Do you have a regular Veterinarian?
If yes, Phone Number:
Veterinarian Name: Hospital Name:
For your convenience would you like your records
transferred from your regular/previous hospital?:

 

Pet Information

 

Pet’s Name:
Canine/Feline: Breed: Color:
Gender: Altered:
Recent Vax Date: Date of Birth:
Pet’s Name:
Canine/Feline: Breed: Color:
Gender: Altered:
Recent Vax Date: Date of Birth:
Pet’s Name:
Canine/Feline: Breed: Color:
Gender: Altered:
Recent Vax Date: Date of Birth:
Pet’s Name:
Canine/Feline: Breed: Color:
Gender: Altered:
Recent Vax Date: Date of Birth:

 

Payment Policy

 

In order to continue to provide humane treatment of companion animals in our shelter and community, payment for services is expected at the end of your visit. A deposit is required if your pet is hospitalized for medical services.

I certify that I am over 18 years of age. I understand that if regular account credit facilities are approved a finance charge of 1.5% (18% per annum) will be charged on all unpaid invoices 30 days from invoice date on the unpaid principal. I agree to pay for services rendered:

Appointment Date: Appointment Time:
Owner’s Signature: Date:

 

Shelter & Adoption Center

Wed            12pm – 8pm
Thu - Sun    11am – 6pm

Mon - Tues   CLOSED

(415) 568-3058 adopt@petsunlimited.org

Veterinary Hospital

Open 24 Hours
Every Day
Main: (415) 563-6700
Fax: (415) 775-2573
Pharmacy: (415) 568-3016

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