New Patient Intake Form

Today's Date:*

OWNER INFORMATION

Owner's Name*

Street Address*

City*

State*
AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

Zip Code*

Cell Phone Number*

Other Phone Number

Your Email*

Employer

Work Phone

Best Form Of Contact*
PhoneTextEmail

We accept cash, Care Credit, debit cards, Visa, MasterCard, American Express, and Discover Cards. WE ARE SORRY, PERSONAL CHECKS CANNOT BE ACCEPTED FOR FIRST TIME CLIENTS.

What is your preferred method of payment?*
CashCareCreditDebit CardsVisaMasterCardAmerican ExpressDiscover Card

Emergency Contact Name*

Emergency Contact Phone*

How did you hear about us?

PET INFORMATION

Pet's Name*

Age*

Type*
DogCatHorse

Breed

Color

Sex
MaleFemale

Spayed/Neutered?
YesNo

Birthdate

Micro-chipped?
YesNo

Current medications your pet is taking

Anything else we need to know?

AUTHORIZATION
I hereby authorize the veterinarian to examine, prescribe for, or treat the above described pet. I assume responsibility for all charges incurred in the care of the animal. I also understand that all professional fees are due at the time services are rendered.

Signature of responsible party:

Date

The information on this form is strictly confidential and is to be used only by this practice to provide care and treatment for your pet.

AT YOUR REQUEST WE WILL GLADLY DISCUSS COST OF SERVICES and/or PREPARE A WRITTEN ESTIMATE FOR RECOMMENDED PROCEDURES.

Check here if you DO NOT wish to have your pets name/picture displayed on our website, Facebook, or any other promotional materials:
I do not want my pet's name or photo featured on any promotional materials.