New Patient Form

Owner Information

Name*

First Last

Birthdate

Home Phone

Cell Phone

Address

Street Address Address Line 2 City State ZIP Code

Email*

Sex

Male
Female

Relationship Status

Employer

Occupation

Work Phone

Work Address

Street Address Address Line 2 City State ZIP Code

In case of an emergency, who should we contact?

Emergency Phone

Whom may we thank for referring you?

Pet Information

Pet's Name

Age/Birth Date

Sex

Male
Female

Species

Cat
Dog

Breed

Weight

Spayed/Neutered?

Yes
No

At what age?

Where did you obtain this pet?

At what age did you obtain this pet?

For what purpose was this pet obtained?

Diet

Kind of pet food

Prior illness?

Prior Surgery?

Describe the reason for pet's visit.

Payment

We will gladly prepare a written estimate if you desire (please ask our receptionist). All professional fees are due at the time services are rendered. In cases of expensive medical or surgical procedures where full payment may be difficult at discharge, we accept major credit cards or can establish a payment arrangement if approved in advance of the treatment. There will be a service charge for any check returned unpaid.

To prevent the spread of infectious diseases, all hospitalized patients must be current on all vaccines and free from internal and external parasites. The signature below authorizes this level of preventative care and the appropriate charges will be assessed in the discharge invoice.

Today's Date*

Signature of client responsible for pet:*

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Owner Information

Pet Information

Payment

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