Welcome Form

Date: *

Date

Owner *

Address *

Street Address

Street Address Line 2

City State (NJ, NY, etc.)

Zip Code

Primary Phone *

Cell Phone *

Work Phone

Spouse

Emergency Contact

Emergency Phone

Email *

example@example.com

What is your preferred language? *

English Español 한국어

Are you considered a Senior Citizen? *

Yes No

Only legal adults are allowed to make decisions regarding a pet. Are you at least 18 years of age? *

Yes No

Were you referred to our hospital?

Yes No

If yes, by whom?

Name of Pet *

Please Select: *

Dog Cat

Breed *

Color *

Birth Date *

Or approximate birthday if unknown

Please Select One: *

Male, Intact Male, Neutered Female, Intact Female, Spayed

Name of Previous Animal Hospial *

Please provide proof/records of vaccinations and any pertinent medical history

This pet has a history of the following:

Anxiety Aggression

If you selected 'Aggression', which of the following is the pet reactive to?

People Dogs Cats

Please check any of the following symptoms or problem that have noticed about your pet:

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

WELCOME FORM

Pet History Form