New Client Information

Welcome to Pearl Animal Hospital! We look forward to meeting you and your pet(s). Please fill out the following form and we will be in touch with you within 48-72 business hours to schedule your initial visit.

Please be advised that we require a refundable deposit equal to the cost of the initial examination due at the time of scheduling.

Thank you and we cannot wait to meet you!

Owner Name*

First NameLast Name

Owner Pronouns*

Phone Number*

Area CodePhone Number

Co-Owner Name

First NameLast Name

Co-Owner Pronouns

Phone Number

Area CodePhone Number

Address*

Street Address

Street Address Line 2 (Apt/Unit#)

CityState

Postal / Zip Code

Email*

example@example.com

Secondary Email

example@example.com

How Did You Hear About Us?*

If you chose Friend Referral, who referred you? *

First and Last Name

If New Adoption, where did you adopt from and when?*

Pet Name*

Species:*

CanineFeline

Breed: *

Color*

Sex:*

FemaleMale

Spayed or Neutered:*

YesNo

Microchipped?*

YesNo

Birthdate

Date

Age*

Pet Insurance Company*

Pet Insurance Company/Policy Number

If you chose other, please let us know which company in this line. Include policy number

For insurance submission, many companies make it easy for you to submit insurance through an app or on your own.

We are happy to submit insurance and medical records on your behalf if your insurance company will allow. Please provide a blank, signed and not dated form at your first visit.

We will always send you copies of your invoices.

If you have a blank, signed (not dated) form, please upload here to keep on file.

Browse Files

To help us best prepare for your visit, please provide a detailed list of the previous veterinary clinics your pet has visited so that we may request records.

A full medical history allows us to make the most appropriate recommendations based on your pet's individual needs. This includes proper vaccination recommendations and lab testing.

Please include the name, state, and phone number (if available) of every veterinary clinic (include ER, urgent care, and specialty hospitals) your pet has visited.

Please include all adoption records you have since it can be very diffcult to obtain records from adoption facilities.

Previous Veterinary Hospitals your dog/cat has been seen (Include adoption/rescue agency if applicable): *

Please provide name of Veterinary Clinic or Rescue, city, and state if outside Portland

Please upload any medical history and adoption records you may have for your pet.

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We will also call previous veterinary hospitals for full medical records.

Where did you get your pet? *

How long have you had your pet? *

What states/countries has your pet traveled to? *

Do you have any other pets or children in the household? *

Please be specific.

Any pertinent medical history? *

Any chronic illnesses or diseases we need to know about?

Has your pet had surgery or an anesthetic procedure before? *

Please be specific and list all known procedures, with dates if known

Has your pet been anxious or fearful for veterinary visits in the past? *

Has a veterinarian ever recommended or prescribed an anxiolytic (anti-anxiety medication) for your pet in the past?*

YesNo

If you chose yes above, please tell us about the medication (trazodone/gabapentin/etc.) and how your pet did with the medication. *

To help facilitate a comfortable examination, we can provide a Fear Free dose of an anxiolytic prior to your pet's visit. We want to be able to provide the least stressful and best possible experience for you and your pet. Would you like us to prepare a Fear Free Dose ($5-$10) for your pet's initial visit?*

YesNoI'm unsure, please discuss with me more.

Are there any specific issues you would like addressed at your initial visit? Do you have a specific goal for your initial visit?*

Please share a picture of your pet for their medical record. *

Browse Files

This photo is for internal use only and will not be shared to social media.

Do we have permission to use photographs/video of your pet on our website, Facebook, or Instagram?*

YesNo

All services must be paid in full at the time services are rendered.

We accept Cash, Visa, Mastercard, American Express, Discover, Debit Cards, and Care Credit. We do not accept personal checks.

As a pet guardian, you will be held liable for the financial responsibility of services that are performed for each pet. Payment is due, in full, at time of service. Unpaid balances will be recovered as deemed appropriate by Pearl Animal Hospital management.

Please initial that you agree and understand our fee policy. *

We understand that life can be unpredictable, and sometimes appointments need to be missed due to emergencies or other commitments. To help us accommodate all our clients, we kindly request at least 2 full business days' notice for any cancellations or rescheduling.

However, if a cancellation or rescheduling request is made with less than 1 full business day’s notice, the following fees will apply:

Late Fee: Clients will be charged a late fee if more than 10 minutes late to an appointment.

New Patients: We require a deposit equivalent to the cost of the exam due at the time of scheduling. If you need to cancel or reschedule, please notify us with a minimum of one full business day to refund your deposit. Deposit will be forfeited if one full business day's notice is not provided prior to cancelling the appointment. Exceptions may be made for an emergency.

Procedures: We require a deposit of $150 due at the time of scheduling. If you need to cancel or reschedule, please notify us with a minimum of one full business day to refund your deposit. Deposit will be forfeited if one full business day's notice is not provided prior to cancelling the procedure. Exceptions may be made for an emergency.

Established Patients: If more than 20 minutes late to a technician or doctor appointment or one full business day's notice is not provided prior to cancelling appointments a fee equivalent to the cost of the exam will be charged. Exceptions may be made for an emergency. No deposit will be required for examinations or technician visits for established patients. This fee will be charged to the most recent debit or credit card used at the clinic. We will not be able to provide services until fees are resolved.

Missing three appointments (no-shows or late cancellations) within a 6-month period, without providing at least one full business day's notice, may result in discharge from care at Pearl Animal Hospital.

Pearl Animal Hospital will send an email to document each no-show or late cancellation. In the event of discharge from care a written notification will be sent along with a complete copy of your records by email.

Clarification on Our Cancellation Policy

Please note that Pearl Animal Hospital requires one full business day (Monday through Friday, 8:00 AM to 6:00 PM) to cancel or reschedule an appointment in order to receive a deposit refund or avoid a late cancellation fee.

This means the policy is not based on a 24-hour countdown, but rather on business operating hours. A few examples:

If your appointment is on Thursday, you must cancel or reschedule no later than Wednesday at 8:00 AM.

For a Monday appointment, you must cancel or reschedule by Friday at 8:00 AM, since we are closed on weekends.

We hope this helps clear up any confusion, and we truly appreciate your understanding as we work to respect everyone’s time and keep our schedule running smoothly. By signing below, you confirm that, should you choose to schedule a procedure or appointment at PAH, you agree to the terms outlined above.

Please sign that you understand and agree to the late, cancellation, no-show policy*

Multnomah County Requires all veterinarians administering rabies vaccinations to report client and pet information, including address, telephone number, breed information, and the date the rabies vaccine was given, to Multnomah County Animal Services.

*Please note that all phone calls are recorded for quality assurance.

We are required to provide medical records when requested by attending veterinarians and those listed on this form unless otherwise indicated.

I have read and abide by the above statements:*

Today's Date*

Date

New Client Information

Patient Information

Fee Policy

Late, Cancellation, No-Show Policy