Welcome Form

WELCOME FORM

Thank you for the opportunity to care for your pet. We’ll be happy to answer any questions you have about your pet’s health. To insure the best care possible, please take the time to fill in this form completely.
Date: *

Month Day Year
Date
Owner *
Address *

Street Address

Street Address Line 2

City State

Zip Code
Primary Phone *
Cell Phone *
Work Phone
Spouse
Emergency Contact
Emergency Phone
Email *
example@example.com
Are you considered a Senior Citizen? *

Yes No
How did you find out about our hospital?

Internet Recommendation
Name of Pet *
Please Select: *

Cat Dog
Breed *
Please Select One: *

Male, Intact Male, Neutered Female, Intact Female, Spayed
Color *
Birth Date *

Month Day Year
Or approximate birthday if unknown
Please check any of the following symptoms or problem that have noticed about your pet:

Breathing Trouble Bloody Stool Coughing Diarrhea Excessive Itching Frequent Urination Growths Lethargy Limping Not Eating/Drinking Red/Watery Eyes Runny Nose Scooting Shaking Head Sneezing Strange Behavior Vomiting
I hereby authorize Dr. Kim and the staff of Ridgefield Park Animal Hospital to examine, prescribe for, and/or treat the above described pet. I assume responsibility for all charges incurred in the care of this animal. I also understand that charges will be paid at the time of release and that a deposit will be required for surgical treatment. It is also agreed that if I do not pay this account as agreed that past due accounts are subject to all reasonable collection costs, including collection agency and/or attorney’s fees and any service charges for account over 60 days old equal to 1.50% per month which is an APR of 18%.
Owner Signature *

Clear
PHOTO CONSENT (OPTIONAL)

This form is for the use of publishing pictures of your pet(s) on our business social media.

I hereby grant Ridgefield Park Animal Hospital permission to use any photographs taken of myself or my pet, in an all publications, including social media, without payment or other compensation. I understand and agree that these materials become property of the Ridgefield Park Animal Hospital and I so authorize to edit, alter, copy, exhibit, publish, or distribute this photo for purposes of publicizing their programs. I understand the employees will be taking pictures with my pet(s) for business social media use only. In signing this consent, I give authorization to use my pet’s name as printed below and that my pet(s)’ nametag will not be shown.
Owner Signature

Clear
Should be Empty:

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WELCOME FORM