New Patient Form

Thank you for visiting our hospital. We look forward to getting to know you and your pet. Please help us to provide the best care possible for your pet by taking a moment to fill out this form.

Practice

Patient's Name *

Client / Owner Information

Name *

Occupation

Driver's License # *

Date of Birth *

Month

Day

Year

Address *

Address Cont'd

City *

State *

ZIP *

Home Phone *

Cell Phone *

Work Phone *

Email *

Spouse / Co-Owner Information

Name

Occupation

Cell Phone

Work Phone

How did you hear about us?

Other

Doctor Referral

If you have been referred to us by another veterinarian, please provide their information below.

Doctor's Name

Hospital Name

State

Phone

Please tell us about your pet(s)

Name *

Type of Pet *

Other

Breed *

Color

Date of Birth *

Month

Day

Year

Sex *

Spayed / Neutered? *

Please tell us about your pet(s)

Name

Type of Pet

Other

Breed

Color

Date of Birth

Month

Day

Year

Sex

Spayed / Neutered?

To prevent the spread of infectious diseases and parasites, hospitalized and boarded animals must be current on all vaccines and free of internal and external parasites to enter our hospital for surgery, boarding, drop off or hospitalization.

I hereby certify that I am the legal owner of the below-listed pet(s) and accept full financial responsibility for their treatment and care. I authorize the doctors of Haines Road Animal Hospital to provide medical treatment, vaccines, and parasite control for my pet(s).

Initials *

I authorize Haines Road Animal Hospital to release my pet’s records to other vets, boarding facilities, etc.

Initials *

I hereby authorize the veterinarian to examine, prescribe for or treat the above-described pet(s). I assume responsibility for all charges incurred in the care of this animal. I also understand that these charges must be paid in full, at the time of release of the pet.

I agree *

Yes

New Patient Form

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