Chico Animal Hospital - New Patient Form

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Welcome

We are pleased to welcome you to our practice! Please take a few minutes to fill out this form as completely as you can. If you have questions we'll be glad to help you. We look forward to working with you in maintaining your pet's health.
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Primary Owner* This field is required.
First Name
Last Name
Home Phone
Cell Phone
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Primary Owner's Email* This field is required.
example@example.com
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Is there a Spouse/Co-Owner?* This field is required.
YESNO
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Spouse/Co-Owner* This field is required.
First Name
Last Name
Cell Phone
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Spouse/Co-Owner Email
example@example.com
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Address* This field is required.
Street Address
Street Address Line 2
City
Please Select
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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Owner's Date of Birth* This field is required.
Date
Month
Day
Year
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Owner
Driver's License
Employer
Business Phone
Google
Location
Internet
Other
Yellow Pages
Yelp
Veterinarian
Person
How did you learn about our practice? (Please select all that apply)
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If Other , Please Specify
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If Veterinarian , Please Specify
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If Person , Please Specify
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Preferred Method of Contact?* This field is required.
First
Second
Third
Fourth
Do Not Contact
Cell Phone (Text)
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Cell Phone (Voice)
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Home Phone
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Email
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Cell Phone (Text)
Cell Phone (Voice)
Home Phone
Email
First
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Second
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Third
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Fourth
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Do Not Contact
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First
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First
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Pet Information
Pet's Name
Dog
Cat
Rabbit
Rat
Guinea Pig
Hamster
Mouse
Species
Age / Birth Date
Color
Female
Female/Spayed
Male
Male/Neutered
Sex/Neutered/Spayed
Previous Veterinarian
Previous Veterinarian Phone Number
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Breed* This field is required.If your pet is a mixed breed, please type in "Mixed"
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Please enter the Primary breed of your pet* This field is required.
17
Do we have your permission to use the image of your pet on social media/public use?* This field is required.By selecting yes, you consent to allowing Chico Animal Hospital to use your pet's image for media/public use.
Yes
No
18
Appointment Information

When scheduling an appointment, a deposit of $70 will be charged and will be applied to the cost of your first visit. A deposit of $120 will be charged for pocket pet exams.

Please allow up to 7 business days for a staff member to reach out to schedule. If you have not already requested an appointment, you will be given the opportunity to complete a Request Appointment form once you finish the new Patient form.

The appointment must be confirmed prior to 2pm the day before. Anything that has not been confirmed will be rescheduled.
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Forms of Payment

We accept Cash, Amex, Visa, MasterCard, Discover, Debit & Care Credit.

All professional fees are due at the time service is rendered. In cases of extensive medical or surgical procedures, a pre payment may be required.
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Signature* This field is required.Signature of client responsible for pets or duly authorized agent (you must be over the age of 18 to sign as the responsible party for your pet).
ClearPlease use your mouse or finger to sign.
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Digital Signature* This field is required.
Please type your signature
22
Today's Date* This field is required.
Date
Month
Day
Year
23
Have you already scheduled your pet's appointment?* This field is required.
Yes
No
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Please tell us what your pet's appointment is for.* This field is required.
Should be Empty:

Welcome

Appointment Information

Forms of Payment