New Client Form

If you’re looking to become a new client here at Ark Veterinary Hospital, we can’t wait to meet you! Please complete the following forms prior to your pet’s first appointment with us. If you need immediate assistance, please call us at 330-262-3465.

Name *

First

Last

Email *

Primary Phone *

Secondary Phone

May we call you? *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Employer

Who else is authorized to make decisions about your pet's healthcare?

First

Last

Phone

How did you learn about our clinic?

Sign Outside
Yellow Pages
Social Media
Website
Newspaper
Recommendation
Other

Whom should we thank? *

If Other, please explain. *

Previous Veterinary Clinic

Previous Veterinary Clinic Phone

Upload Pet Records

Click or drag a file to this area to upload.

Records can also be sent to our email ark.office@arkvethosp.com and fax number 330-262-3462.

Pet's Name *

Species

Canine
Feline
Other

Other Species: *

Breed *

Color *

Age/Date of Birth *

Sex *

Male
Neutered Male
Female
Spayed Female

Vaccine History

Please check any symptoms or problems that you have noticed about your pet

Behavioral Problems
Bleeding Gums
Breathing Problems
Coughing
Diarrhea
Eye Bulging or Bloodshot
Gagging
Lack of Appetite
Limping
Loss of Balance
Scooting
Scratching
Seems Depressed
Shaking Head
Sneezing
Thirst and/or Urination Increased
Vomiting
Weakness
Other

If Other, please explain.

Please list current medications (if any)

Describe your pet's diet

I hereby authorize the veterinarian to examine, prescribe for, and/or treat the above described pet. I assume full responsibility for all charges incurred for the care of the animal. I also understand that these charges will be paid at the time of the release and that a deposit may be required for surgical treatment. *

I have read and understand.

Signature *

Today's Date *

Method of Payment *

Cash
Check
Mastercard
Visa
Other

Other payment option: *

Website

Ready for a visit?

We provide veterinary services with courtesy and respect to the pets of Wooster, OH, the greater Wayne County area, and the surrounding areas. We look forward to your next visit! You may request an appointment by clicking the button below.

Appointment

New Client Form

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