Client Registration Form – Holt Veterinary Clinic

Holt Veterinary Clinic Client Registration Form

Please do not use this form for submitting medical questions about a patient's condition or for requesting an appointment. This form is only to be used for creating a new client and patient account.

PLEASE NOTE - It may take up to 72 hours for a reply; If this is an urgent matter please call the clinic at 517-694-9510

Today's Date:

Client's Name *

First

Last

Spouse/Partner Name

First

Last

Client's Address *

City *

State *

Zip Code *

Home Phone *

Paragraph Text

Work Phone

Cell Phone

Email Address

Client's Employer's Name

Client's Employer's Address

City

State

Zip Code

Client's Employer's Phone

Pet's Name *

Species *

Canine
Feline

Pet's Breed *

Pet's Gender *

Male
Female

Is Your Pet Already Spayed/Neutered?

Pet's Description/Color *

Pet's Age *

Pet's Date of Birth (If known)

Additional Pet Information

Date of Scheduled Appointment

Reason for Scheduled Appointment

Does your pet have any previous history of medical issues? Please explain.

Please send copies of previous veterinary records to us at holtvetclinic@gmail.com or fax to 517-699-8932. If you need us to call for the records, which clinic(s) should we call?

Did someone recommend our clinic to you? If so, please tell us their name so we can thank them for the referral!

Phone