New Client Intake Form Name * First Name Last Name Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### Email * Please check the preferred way you want to be contacted for your appointment reminders, care and follow-up discussions: * Text Email Phone Pet Name and Breed * Age/ Date of Birth * Sex * Male Female Weight (Est, OK) * Spayed/ Neutered * Yes No Check Vaccine Up to Date * Rabies DHPP Lepto Flu Bordetella How did you hear about Cle K9 Rehab? Name of Primary Veterinarian * Veterinary Hospital/ Clinic Name & Phone * Please list all your health concerns for your pet for your rehabilitation consultation and treatment: * Do you give CLE K9 Rehab permission to share your pet's medical care with your primary care veterinarian if indicated or requested? * Yes No Thank you!