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New Patient Form

Location

Patient's Name(Required)

CLIENT / OWNER INFORMATION

Name(Required)

Address(Required)

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Email(Required)

Home Phone(Required)

Cell Phone(Required)

How would you prefer us to contact you?

Phone

Text

Work Phone(Required)

Occupation

Employer's Name and Address

We will gladly prepare a written estimate if you desire. Please ask the receptionist or doctor. PROFESSIONAL FEES ARE DUE AT THE TIME SERVICES ARE RENDERED.

We accept VISA, MASTERCARD, DISCOVER, AMERICAN EXPRESS, CASH, AND CARE CREDIT. If you plan to use a credit card or Care Credit, please provide your driver’s license to the receptionist to make a copy.

Driver's License #(Required)

Date of Birth(Required)

Height

SPOUSE / CO-OWNER INFORMATION

Name

Cell Phone

Work Phone

Occupation

Employer's Name and Address

EMERGENCY CONTACT

In case of emergency, who should we contact?

Phone Number

HOW DID YOU HEAR ABOUT US?

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

State / Province / Region

Phone

PLEASE TELL US ABOUT YOUR PET(S)

Name(Required)

Type of Pet(Required)

Other

Breed(Required)

Color

Date of Birth(Required)

Sex(Required)

Spayed / Neutered?(Required)

PLEASE TELL US ABOUT YOUR PET(S)

Name

Type of Pet

Other

Breed

Color

Date of Birth

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 and EDGE Animal Hospital to provide medical treatment, vaccines, and parasite control for my pet(s).

Initials for social media authorization

I authorize Haines Road and EDGE Animal Hospital to use my pet’s pictures on social media.

Initials for release of records

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

Initials for treatment by veterinarian authorization

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.

Signer Name(Required)

Signature(Required)

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New Patient Form

CLIENT / OWNER INFORMATION

SPOUSE / CO-OWNER INFORMATION

EMERGENCY CONTACT

HOW DID YOU HEAR ABOUT US?

DOCTOR REFERRAL

PLEASE TELL US ABOUT YOUR PET(S)

PLEASE TELL US ABOUT YOUR PET(S)

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Get in touch

727-525-2118

727-525-2118

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