New Client Form

Welcome to our hospital! We look forward to serving you and your pets.

Per the New Mexico Veterinary Medical Associations Act full and accurate medical records must be kept on all clients. Please take a few minutes to fill out all blanks for us.

Name

First Middle Last

Home Phone

Mailing Address

City State / Province / Region ZIP / Postal Code

Street Address

City State / Province / Region ZIP / Postal Code

E-Mail Address

Cell Phone

Spouse or Co-Owner’s Name

Cell Phone

Your employer

Phone

Co-Owner’s Employer

Phone

Driver’s Licenses:

Yours:

Number

Expires

Date

Co-Owners:

Number

Expires

Date

In case of an emergency and we can not contact you would you please indicate the nearest relative not living with you below:

Name

Phone

Who may we thank for referring you to our hospital?

Reminder Preference: We can now mail or e-mail your reminders for vaccinations, etc. Please circle your preference:

U S Postal

E-Mail

Text

I give permission for photos of my animals to be used on Village Veterinary Social Media/Brochures.

Yes

No

Signature

If you own large animals which might require our doctor to come to your house for service in the future, and your house might be difficult to find, please use the space below to draw a small map to your house.