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Home New Patient Form

New Patient Form

Patient's Name

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.

CLIENT / OWNER INFORMATION

Name

First

Last

Address

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country

Home Phone

Cell Phone

How would you prefer us to contact you?

Phone

Text

Work Phone

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, 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 #

Date of Birth

MM slash DD slash YYYY

Height

SPOUSE / CO-OWNER INFORMATION

Name

First

Last

Cell Phone

Work Phone

Occupation

Employer's Name and Address

EMERGENCY CONTACT

In case of emergency, who should we contact?

Phone

HOW DID YOU HEAR ABOUT US?

How did you hear about us?

Friend

Internet

Telephone Book

Drive By/Saw Our Sign

Other

DOCTOR REFERRAL

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

Doctor's Name

Hospital Name

Phone

PLEASE TELL US ABOUT YOUR PET(S)

Name

Type of Pet

Dog

Cat

Other

Breed

Color

Date of Birth

MM slash DD slash YYYY

Sex

Male

Female

Spayed/Neutered?

Yes

PLEASE TELL US ABOUT YOUR PET(S)

Name

Type of Pet

Dog

Cat

Other

Breed

Color

Date of Birth

MM slash DD slash YYYY

Sex

Male

Female

Spayed/Neutered?

Yes

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

Initials

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

Initials

I authorize EDGE Animal Hospital to release my pet’s records to other vets, boarding facilities, emergency vets, 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.(Required)

Name(Required)

First

Last

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