New Patient Form

Bergen Veterinary Hospital

1154 TEANECK RD.

TEANECK, NJ 07666

(201) 837-3470 Fax (201) 353-3400

www.bergenvet.com
PATIENT/ CLIENT INFORMATION

Thank you for giving us the opportunity to care for your pet(s). Please help us meet your needs better by taking a moment to complete this information sheet.
DATE*

MonthDayYear
Date
Pet Name (s):*
Owner's Name*
Spouse/ Other Name*
Complete Address (Print Clearly)*
Primary phone #*
Secondary Phone #*
Primary Email*
example@example.com
- Please let us know if you would like a written estimate for any procedure(s).
- Professional services are due in full at the time services are rendered.
- Please provide your driver's license for our file.
- If you would like us to retain your credit card information, please inform the front desk staff.
How did you hear about our hospital?*

Individual, someone we may thank?AAHA/ Hospital RefferalOnline search engine (Google, yelp, etc.)Advertisements (flyers, posters, coupons)Hospital SignWebsiteOther
If you selected individual, please provide his or her name if you would like.
If you selected search engine, please specify which one.
I hereby assume responsibility for ALL charges incurred in the care of the following patient(s). I also understand that these charges are to be paid in full at the time of service.

If a balance is outstanding agaisnt hospital policy, I agree and understand that I WILL BE charged Finance and End of the Month Billing Charges for ALL outstanding amounts until the bill is PAID IN FULL
Form of Payment (Choose Applicable Choice)*

CashCheckCredit CardDebit Card
I further agree that I have signed this document of my own free will and that this agreement is subject to both federal and state laws.
Owner's Printed Electronic Signature *
Date*

MonthDayYear
Date
Responsible Party's Printed Electronic Signature *
Date*

MonthDayYear
Date
TELL US ABOUT YOUR PET
Pet Name*
Species (Circle One)*

CanineFelineAvianRabbitFerretOther
DOB*

MonthDayYear
Date
Breed*
Gender*

MaleFemale
Spayed/ Neutered*

YESNO
Color Markings:
Microchip Company and number:
PET HISTORY
Allergies*
Describe and Date of Occurrence
Previous Medical Problem *
Describe and Date of Occurrence
Current Medications*
Describe and Date of Occurrence
Previous Medications*
Describe and Date of Occurrence
Behavior Problem*
Describe and Date of Occurrence
Lived/ Traveled out of Area*
Describe and Date of Occurrence
Boarded in past 6 months *
Describe and Date of Occurrence
Groomed in past 6 months *
Describe and Date of Occurrence
Other household pets*
Describe and Date of Occurrence
Exposed to other animals/ wildlife *
Describe and Date of Occurrence
Exposed to other animals/ wildlife *
Describe and Date of Occurrence
Where does the pet spend the majority of its time?

IndoorsOutdoorsBoth
DIET
Kind of Food*
Amount of Food Per Day:*
Brand*
Treats*
VACCINATION HISTORY
If you have a file of your pet(s) vaccine history, please upload the file directly below. If you do not have a file, please fill out the fields below.
Please upload the vaccination history file here.

Browse Files

Cancelof
VACCINE (DOG)
Rabies
Most recent date given
Distemper/Parvo
Most recent date given
Bordatella
Most recent date given
Canine Influenza
Most recent date given
Leptosporosis
Most recent date given
Lyme
Most recent date given
VACCINE (CAT)
Feline Distemper
Most recent date given
Rabies
Most recent date given
Feline Leukemia
Most recent date given
FeLV/FIV Test
Most recent date given
TEST HISTORY
Heartworm Test
Date Completed
Fecal Exam
Date Completed
Bloodwork
Date Completed
Physical Exam / Checkup
Date Completed
Additional History/ Information
Should be Empty: