New Client FormPlease enable JavaScript in your browser to complete this form.DateEmail *Name *FirstLastAddress *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePrimary Phone Number *Alternative Contact/PhoneCounty of Residence:Multnomah Washington Clackamas OtherPreferred Contact Method:Phone Email Text MessageNo preference - all three are ok How did you hear about us?If a Personal Recommendation - who can we thank? Internet/Other (which search engine?):Saw Your Mobile Clinic around my neighborhoodAccepted Methods of PaymentPayment is required at the time of service. For your convenience, we accept Mastercard, Visa, Discover, American Express, cash, or check (with a valid driver’s license). We also accept Care Credit and pet health insurance.ConsentYou will be asked to sign or verbally approve a health plan confirming or declining authorization of treatment after a tentative diagnosis. The details of treatment, the risks of treatment, and/or the risk of not treating will be explained to you.Photo ConsentI grant permission to Blue Door Veterinary Services, LLC for the use of the photograph(s) or electronic media for the purposes of marketing or education. I understand that I may revoke this authorization at any time by notifying Blue Door Veterinary Services, LLC in writing. The revocation will not affect any actions taken before the receipt of the written notification. Images will be stored in a secure location and only authorized staff will have access to them. They will be kept as long as they are relevant and after that time destroyed or archived.With my signature below, I certify that I have read and agree to the above statements and authorize Blue Door Veterinary Services, LLC to treat my pet(s).SignatureDatePet information (1st Pet)Name *Age/Birth DaySpecies (cat, dog, etc.) *BreedColorAvg WeightMaleFemale Spayed/neutered?YesNo Does your pet have allergies?YesNoIf yes, please explain allergy issue: Has your pet ever had a reaction to vaccines or medications?YesNoIf yes, please explain vaccine or medication reaction:List any major surgeries/illnesses your pet has had:List any behavior problems we need to be aware of/ any concerns for interaction with the vet team:List any foods and treats you give your pet (quantities per day would be helpful!): Previous Vet who might have records on this pet (by completing this section, you are giving permission for us to reach out for historic medical records):Pet information (2nd Pet)NameAge/Birth DaySpecies (cat, dog, etc.) BreedColorAvg WeightMaleFemale Spayed/neutered?YesNo Does your pet have allergies? YesNoIf yes, please explain allergy issues: Has your pet ever had a reaction to vaccines or medications?YesNoIf yes, please explain vaccine/medication reaction:List any major surgeries/illnesses your pet has had:List any behavior problems we need to be aware of/ any concerns for interaction with the vet team:List any foods and treats you give your pet (quantities per day would be helpful!):Previous Vet who might have records on this pet (by completing this section, you are giving permission for us to reach out for historic medical records):Submit