New Patient Form

New Client Form

    Thank you for giving us the opportunity to care for your cat. Please help us meet your needs better by taking a moment to complete this information sheet.

    November 9, 2020

    At this time, we are asking all New Clients to place a non-refundable “New Patient Pre-Payment” of $75 to hold your appointment spot. The Pre-Payment will apply to your charges on the day of your appointment. The Pre-Payment will be forfeited if you are a “No-Show” for that appointment.

    CONTACT INFORMATION:

    Date*

    Primary Owner's Name*

    Primary Owner's Last Name

    Primary Owner's First Name

    Patient Name*

    Secondary Owner's Name*

    Secondary Owner's Last Name

    Secondary Owner's First Name

    Primary Address*

    Primary Street Address *

    Primary State/City *

    Primary Zip *

    Primary Home Phone*

    Primary Work Phone

    Primary Cell Phone

    Primary Employer Information*

    Employer Name*

    Primary Employer Address*

    Secondary Employer Information

    Employer Name

    Secondary Employer Address

    Secondary Home Phone

    Secondary Work Phone

    Secondary Cell Phone

    PATIENT INFORMATION:

    Patient Name*

    Reason For Visit?

    Breed*

    Sex of Cat*

    Male Castrated (MC)

    Female Spayed (FS)

    Coat Color*

    Birthdate*

    Type of Food/Brand

    Type of Litter/Brand

    Microchip#

    Declawed

    Date of last Vaccination:

    Distemper

    Rabies

    Leukemia

    What prior illnesses, surgery, or drug allergies should we know about?

    How Did You Hear About Us?

    Other

    If Referred By an Individual or Veterinarian? Please list their name below.

    Referred by an Individual Individual Name Referred by

    Referred by an Another Veterinarian: Veterinarian Name Referred by

    PAYMENT POLICY: We accept cash, Visa, Mastercard, Discover, American Express and Travelers checks. If you pay by check, please complete the following:

    Driver's License Number/State*

    I UNDERSTAND THAT ALL PROFESSIONAL AND HOSPITAL FEES ARE DUE AT THE TIME SERVICES ARE RENDERED AND MUST BE PAID IN FULL. I ACKNOWLEDGE THAT A DEPOSIT MAY BE REQUIRED FOR ANY PATIENT NEEDING TO BE HOSPITALIZED.

    We will gladly prepare a written estimate if you desire. Please ask the doctor.

    TO PREVENT THE SPREAD OF INFECTIOUS DISEASES AND PARASITES, HOSPITALIZED ANIMALS MUST BE CURRENT ON ALL VACCINES AND FREE OF INTERNAL AND EXTERNAL PARASITES. I AUTHORIZE THE DOCTOR TO PROVIDE VACCINES AND PARASITE CONTROL AS NEEDED FOR MY PET.

    Please bring to your appointment any previous Veterinary records or upload an electronic copy below

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