New Patient Form

Owner's Full Name*
Please mention the first name and last name both
Cell Phone*
Alternate / Emergency phone number*
Email*
Home address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Driver's License #
Employer
Work Phone
Spouse/ Partner
Spouse/Partner Phone
Would you prefer to receive text or calls for some reminders for your pet?*

TextCall
Do you give us permission to release your pets’ vaccine records to other hospitals, boarding facilities and/or grooming shops when they are requested by them?*

YesNo
Will you allow us to post your pets’ picture on our social media sites? We will never publish any of your personal information or any medical problems your pet may be having.*

YesNo
Do you have pet insurance?*

YesNo
If yes, what company?

Your Pet's information*

How did you hear about us?*

AAHAClinic SignFriend/ Family ReferralNewspaperOnline SearchOther Vet PracticeSocial MediaOther
Name of Referral
I, the undersigned legal owner of the above-described pet(s), certify I am eighteen (18) years of age or older, and hereby authorize the veterinarian to examine, prescribe for, or treat the above described pet. I assume responsibility for all charges in the care of this animal. No warranty or guarantee has been made as to the result or cure.
ALL FEES ARE REQUIRED TO BE PAID IN FULL UPON COMPLETION OF THE VISIT.
In the event any balance due hereunder is not paid as agreed, the undersigned jointly and severally agree to pay all cost included in said unpaid balance, including a collection and/or attorney’s fees.
Owner's Signature*
Type Your Name
Date*

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Date
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