New Patient Form

We are excited that you have chosen the Delano Veterinary Clinic to serve you and your furry family members. Please complete the New Client form below so we can best be prepared for your appointment.

First Name

Last Name

Preferred Phone #

Street Address

City

State

ZIP

Secondary Contact Name

Relationship to Pet Owner

Phone #

How did you hear about us?

Is there a name of someone we may thank for referring you?

Pet's Name

Date of Birth

Species:

Dog Cat

Sex:

Male Female

Is Your Pet Spayed/Neutered?

Yes No

Type of Breed

Color/Markings

Other facilities frequently request patient history and vaccination records. Please help guide us as to how you would like this information shared.

May we share your pet's patient history and vaccination records with other veterinary clinics and hospitals?

Yes, you may share with other clinics and hospitals.

May we share your pet's patient history and vaccination records with kennels and boarding facilities?

Yes, you may share with kennels and boarding facilities.

Would you prefer not to share any of your pet's information?

Please do not release any of my pet's information.

Records and X-Rays are the property of the Delano Veterinary Clinic. Payment is required at the time of service. Past due balances are subject to a 1.5% per month service charge until paid. I confirm that all information entered is correct and complete and I agree to the aforementioned terms.

I agree.

*Please note: Our clinic accepts local checks, cash, Visa, Mastercard, American Express, and Discover. We do not accept care credit at this time. Thank you for your cooperation.

Monday, Wednesday, & Friday: 8am-5pm
Tuesday & Thursday: 8am-6pm
Saturday & Sunday: Closed

504 Babcock Blvd, Delano MN 55328 DVC@DelanoVeterinaryClinic.com
Phone: 763-972-3534
Fax: 763-972-2244

In the event of an emergency and we cannot be reached please refer to our list of Emergency & Urgent Care Clinics.

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