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New clients

New client & pet form.

Fill it out online and we'll have you in the system before your first visit — or print it and bring it with you. Add every pet in your household to this one form.

R Veterinary — Jefferson City · 4736 Country Club Dr., Jefferson City, MO 65109 · (573) 893-7707

Client information

First name *
Last name *
Email *
Spouse's name
Address
City
State
ZIP
Cell phone
Home phone
Work phone
Place of employment
How did you learn of our clinic?
☐ Internet search ☐ Facebook ☐ Sign ☐ Newspaper ☐ Recommended by someone ☐ Other
If recommended, by whom?
May we release pet records / your contact info when requested? (other vet clinics, boarding & grooming, shelters, or someone who finds your lost pet — Missouri requires your consent)
May we post photos of your pet on the clinic's social media?

Pet information #1

Pet's name *
Species
☐ Dog ☐ Cat ☐ Other
What would you like to schedule for this pet?
☐ Wellness exam & vaccines ☐ Sick or injured visit ☐ Dental ☐ Spay or neuter ☐ Just establishing care (no appointment yet) ☐ Something else
Breed
Color
Sex
Spayed / neutered?
Birthdate or approximate age
Where did you get your pet?
Diet / food
Current medications
Vaccination history (approximate dates of last vaccinations/procedures — Rabies, Parvo/Distemper, FVRCP, Bordetella, …)
Anything you've noticed or want us to know? (appetite, weight changes, concerns)

I authorize the veterinarian to examine, prescribe for, or treat the animals I present, and I assume responsibility for all charges incurred, due at the time of release. A deposit may be required for surgical treatment.

Signature of responsible party
Date