New Patient Form New Patient Form Thank you for giving us the opportunity to care for your pet. Please help us meet your needs better by taking a moment to complete this information sheet. Client InformationDate* MM slash DD slash YYYY Name* First Last Spouse/Other First Last Number Pets*Address* City/St* Zip* Primary Contact Number*Secondary NumberSpouse Contact NumberEmail Addreess* Preferred contact method* Call (Primary Number) Text Email Who may we thank for referring you to our hospital? Pet InformationPet's Name* Sex* Male Neutered Male Female Spayed Female Species* Canine Feline Microchipped?* Yes No Age or Date of Birth* Breed* Color* Special Markings List all current medications / supplements / vitamins your pet is currently taking Vaccination Status* Up to date Needs vaccines Unknown What previous veterinarian can we call for your pet's previous records?* Prior Surgeries/Illnesses Additional Information Primary reason for visit* AuthorizationI hereby authorize the veterinarian to examine, prescribe for, and treat my animal(s). I assume responsibility for all charges incurred in the care of my animal(s). I also understand that payment is due at the time of service. I have read and understand this policy and I accept responsibility for all fees. Family Pet Hospital accepts all major credit cards, cash and Care Credit.Signature of Responsible Party* Date* MM slash DD slash YYYY Please attach a photo of your pet for their medical fileAccepted file types: jpg, jpeg, png, gif.Additional PetsAdditional Pets* Yes No Owner’s Name* First Pet’s Name* First Species* Canine Feline Microchipped ?* Yes No Age* Breed* Color* Special Markings Sex* Male Neutered Male Female Spayed Female List all current medications / supplements / vitamins your pet is currently taking Vaccination Status* Up to date Needs vaccines Unknown Previous Veterinary Hospital* Previous records* Please call previous hospital I will bring records Prior Surgeries/Illnesses Primary reason for visit* Additional Information Need to add another pet?* Yes No Pet’s Name* First Species* Canine Feline Microchipped ?* Yes No Age* Breed* Color* Special Markings Sex* Male Neutered Male Female Spayed Female List all current medications / supplements / vitamins your pet is currently taking Vaccination Status* Up to date Needs vaccines Unknown Previous Veterinary Hospital Primary reason for visit* Prior Surgeries/Illnesses Additional Information Need to add another pet??* Yes No Pet’s Name* First Species* Canine Feline Microchipped ?* Yes No Age* Breed* Color* Special Markings Sex* Male Neutered Male Female Spayed Female List all current medications / supplements / vitamins your pet is currently taking Vaccination Status* Up to date Needs vaccines Unknown Previous Veterinary Hospital Primary reason for visit* Prior Surgeries/Illnesses Additional Information Social Media Consent*I hereby give Family Pet Hospital permission to take photographs and videos of me and my pet for the purpose of posting on Family Pet Hospital's Facebook, Instagram, YouTube, Twitter and Hospital website. I hereby release and discharge Family Pet Hospital from any and all claims arising out of use of the photos. Family Pet Hospital has my permission to use: (check one): Only my pet's name(s) My first name and my pet's first name(s) My first and last name, my pet's first name(s) and last name(s) I decline this Social Media Consent at this time PhoneThis field is for validation purposes and should be left unchanged.
