New Client Information

Client Contact Information

Owner Name*

First Last

Spouse

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Home Phone*

Cell Phone

Email*

Employment Information

Employer

Occupation

Employer Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Employer Phone Number

Veterinarian History

Who referred you to us?

Regular Veterinarian

Veterinarian Phone Number

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Pet/Patient Information

Pet Name*

Pet Breed*

Pet Birthdate*

Pet Sex*

Pet Species*

Dog
Cat
Rabbit

What is your primary concern for Dr. Mathis today?*

Consent*

You have contacted Dr. Mathis for a behavior consultation. Dr. Mathis may also suggest alternative medicine treatments for your pet. Many of these treatments, as well as most of the western medicines available for treating behavior problems, are not officially approved for use in animals, and may be considered experimental by some. Dr. Mathis will make every attempt to keep your pet safe, but drug reactions do happen. Success of treatment is not guaranteed, but is increased by compliance with instructions. You have read the above and understand that alternative treatment may be used on your pet and you accept responsibility for this decision.

Payment in full by check or cash is due after each visit.

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Behavioral New Client Information

Client Contact Information

Employment Information

Veterinarian History

Pet/Patient Information

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