new patient form For new patients, please complete this form. Date * MM DD YYYY Owner's Name * First Name Last Name Email * Driver's License State & Number Spouse/Other Name First Name Last Name Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * Mobile (###) ### #### Phone Home (###) ### #### Phone Work (###) ### #### Phone Spouse/Other (###) ### #### Emergency Contact Name & Phone Number * How did you hear of our hospital? Friend/Family Member Internet Social Media Other Who recommended us? First Name Last Name Name of Previous/Current Veterinarian Policy * DUE TO STATE LAW AND INSURANCE REQUIREMENTS, ALL DOGS & CATS MUST BE CURRENT ON RABIES VACCINATION AND HAVE WRITTEN PROOF OF VACCINATION. To help prevent the spread of infectious diseases, ALL hospitalized and boarded animals must be current on all vaccinations. Vaccination can be updated at the time of your appointment if it is not current. I understand every effort to the best of our ability will be made to achieve a successful outcome for your pet. I hereby authorize this hospital to receive, prescribe for, treat or perform surgery upon the pet(s) listed on the reverse side and additional pets I present. Furthermore, I agree to pay fees for services rendered at the time the pet is discharged from the hospital or when the service is otherwise terminated. I agree to pay for the reasonable costs of collection in the event that collection efforts become necessary. I agree to pay amounts and charges incurred by myself and members of my family. I hereby waive my rights of exemption under the laws of Alabama and any other state. I understand that CheckRedi will assess a service fee of $29.00 for each non-sufficient fund check. All accounts unpaid after 30 days receive a late charge computed at a periodic rate of 1.50% per month, which is an annual percentage rate of 18.00% with a minimum monthly charge of $1.00. I understand that veterinary service is provided during nighttime hours as necessary in the judgment of the veterinarian in charge. Continuous presence of qualified personnel may not be provided. If I neglect to pick up my pet within 5 days of the discharge date and do not notify you within that time period, you may assume that the pet is abandoned and are hereby authorized to dispose of the pet as you deem best and/or necessary. We will gladly prepare a written estimate if you so desire. Please ask a receptionist or doctor. Professional fees are due at time services are rendered. I have read and agree to all terms and conditions. Signature * The undersigned serves as an electronic signature and agreement to all terms and conditions noted herein. Pet Information Pet's Name * #1 Species * Dog Cat Other Other Description Breed & Description (Color & Markings) Age or Date of Birth Sex Male (Intact) Male (Neutered) Female (Intact) Female (Neutered) Unknown Vaccination Date for Rabies MM DD YYYY Heartworm Test/Prevention MM DD YYYY Intestinal Parasite Test MM DD YYYY Medical History - Prior Illness/Surgery Dogs Vaccination Date for DA2PPC (Distemper/Parvo) MM DD YYYY Vaccination Date for Bordetella (Kennel Cough) MM DD YYYY Cats FVRCPC (Infectious Diseases) MM DD YYYY FELV (Feline Leukemia) MM DD YYYY FELV / FIV Test MM DD YYYY Thank you! REGISTER ADDITIONAL PETS HERE