Please Fill Out and Submit the Below Document New Client Form Which District Vet location is your preference?*Brookland- 3748 10th Street, NEEastern Market- 240 7th Street, SEClick here for a map of both locations. Name* First Last Additional Person/ SpouseAddress* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Phone*Email* Spouse / Other's email Pet's Name*Dog or Cat*DogCatBreed (if known)*Color / Colors*Sex*FemaleMaleSpayed or Neutered?*YesNoDate of Birth/AgeAny known allergies, vaccine reactions?*What is your pet's favorite toy?Any allergies to peanut butter in your home?*yesnoPrevious Veterinarian/ Veterinary Hospital*Something interesting about your petHow did you become aware of our hospital?*Drove/ Walk byWebsitePrevious ClientGoogle/BingRescue GroupPersonal ReferralAre you requesting an appointment?*Yes, my pet has an issue right now to be seenYes, we don't have an immediate issue but would like an appointmentWe don't need an appointment right now.What issue is your pet having?*Please describe what we'll see your pet for. When would you like to be seen?* Date Format: MM slash DD slash YYYY Professional fees are to be paid at the time services are rendered. We will gladly provide a written estimate, if you desire. Please ask the receptionist or doctor. We accept all major credit cards for payment. We may require a credit card deposit in order to schedule an appointment. Clients who cancel an appointment with less than 24 hours' notice or who fail to show for their appointment may have their card charged the prevailing examination fee. Surgical no-show clients will be charged a $150 fee. Per District of Columbia regulations, this hospital must now register all dispensed controlled medications. A request may be made to the Prescription Drug Monitoring Program (PDMP) to obtain information on all covered substances dispensed to any patient visiting our hospital. Unless requested otherwise, you give us permission to post tasteful pictures of your pet, identified by pet name only, on our social media pages and website. Please note that unless stated in writing, we will release your pet's medical history to necessary veterinary hospitals and emergency or specialty care facilities when requested or needed. I am responsible and agree to pay in full the total charges for services rendered at the time of discharge and any fees incurred for collection of said charges. I understand that the fees are based on treatment deemed necessary at the time of exam, treatment, or admission and that the estimate fee may be raised or lowered by the administration of treatment, medication, surgery, or diagnostic test.Name*Date* Date Format: MM slash DD slash YYYY Consent* I agree to the terms above.