New Patient Form

Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Primary Phone*

Secondary Phone

WorkPhone

Driver's License #*

Email*

Employer Name & Address*

Spouse/Partner Name

Name

First Last

Spouse/Partner Primary Phone

Spouse/Partner Secondary Phone

Pet Info

Pet's Name*

Age/Date of Birth*

Colour*

Species*

Canine
Feline
Ferret
Avian
Rabbit
Hamster
Reptile
Other

If other

Please Specify

Gender*

Male
Male Neutered
Female
Female Spayed
Unknown

Breed*

Where did you get your pet?*

Previous Veterinary Hospital

May we ask to transfer your pet's records?

Is your pet microchipped? If yes, please enter the microchip number if known.

ALLERGIES?*

Our goal is to do our best to provide a fun, fear free visit for your pets. One of the many tools we use to do that is lots of food rewards of various kinds. Do you or anyone in your family (including your pets) have any food allergies that we should be aware of? If the answer is "yes" please list them in your reply.

Does your pet have an appointment schedule already? If yes, please provide date.*

Reason to Visit*

Is there a particular doctor you would like to see?

How did you hear about us?*

If through a friend, please provide their name so we can thank them!! (Did you know friend referrals get a $15 account credit?)

Method of payment desired

Cash
Credit Card/Debit

***Personal checks are not accepted***

Our financial policy: Payment in full is due when services are rendered. We accept Cash, Debit Cards, Care Credit, Wells Fargo Health Advantage and major Credit Cards. Personal checks are not accepted. A minimum of 30% is required as a deposit for all major surgeries and/or hospitalizations at the time of admittance. Emergency cases require a minimum of 50% of the estimated treatment plan at time of admittance before we can proceed with extensive hospital care. A 1.5% fee per month will be charged on all accounts that are 30 days past due. A $2 billing fee will also be applied each month. We require a 24 hour notice to change or cancel an office appointment. A 48 hour notice is required for surgical/boarding appointment cancellation and/or rescheduling. We reserve the right to charge a fee for a missed, cancelled or rescheduled appointment without required notification.

By typing my name in this box I acknowledge that I am 18 years of age or older, have read the above financial policy and missed/cancelled or rescheduled appointment policy and will adhere to their terms.*

First Last

Monday	8:00am – 7:00pm
Tuesday	8:00am – 7:00pm
Wednesday	8:00am – 7:00pm
Thursday	8:00am – 7:00pm
Friday	8:00am – 5:00pm
Saturday	8:00am – 5:00pm
Sunday	8:00am – 2:00pm

New Patient Form

New Patient Form

Spouse/Partner Name

Pet Info

In this section

EMERGENCY SERVICE AVAILABLE

New Patient Form

New Patient Form

Spouse/Partner Name

Pet Info

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In this section

EMERGENCY SERVICE AVAILABLE