New Client Information

New Client Information
Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Name

First NameLast Name
AUTHORIZED INDIVIDUALS - Please list any additional individuals who are authorized to discuss your pet’s medical care, receive medical information, approve treatment, and make decisions regarding your pet while acting on your behalf.

First NameLast Name
Authorized Individual

First NameLast Name
Authorization

I authorize the individual(s) listed above to receive information regarding my pet’s health and medical records and to approve examinations, diagnostics, medications, treatments, and other services on my behalf.

I understand that I remain financially responsible for all services authorized by me or by an authorized individual listed on my account. This authorization does not transfer ownership of my pet or permit an authorized individual to change ownership information, remove me from the account, authorize euthanasia, or make end-of-life decisions unless I provide separate written authorization.

I understand that it is my responsibility to notify Martin Downs Animal Hospital if I wish to add or remove an authorized individual.
Your Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone Number

Area CodePhone Number
Secondary Phone Number

Area CodePhone Number
May we send appointment reminders and hospital-related messages to your primary phone number by text? Message and data rates may apply.
Email
example@example.com
How did you hear about our clinic?
Personal Referral (Whom may we thank?)

First NameLast Name
Patient Information
If you already have an appointment scheduled, what is the appointment date?

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Name of Pet
Species
Breed
Date of birth or approximate age
Color/Description
Sex
Microchip #
Do you have any more pets to provide information for?
Name of Pet
Breed
Date of Birth
Color/Description
Sex
Microchip #
Does your pet have any fear, anxiety, aggression, or handling concerns that our team should be aware of? Enter “None” if applicable.
Previous Vet Name and Phone Number
Is there any other name the records may be listed under? If yes, please provide.
Do we have your permission to contact the veterinary hospital listed above and request your pet’s medical and vaccination records?
Please list any significant illnesses, injuries, chronic conditions, or surgeries. Enter “None” if not applicable.
Please list all medications and supplements, including the strength, amount given, frequency, and most recent dose. Enter “None” if applicable.
What brand and type of food does your pet eat? Include the amount and frequency.
FINANCIAL ACKNOWLEDGMENT

I understand that payment is due at the time services are rendered. I accept financial responsibility for all services provided to my pet(s), including services authorized by me or by an authorized individual listed on my account.

OUTSIDE PHARMACY POLICY

Martin Downs Animal Hospital does not process electronic, faxed, or telephone prescription approval requests from outside pharmacies. If I choose to use an outside pharmacy, I understand that, upon request, Martin Downs Animal Hospital can provide a written prescription for eligible medications during my pet’s appointment or have it available for pickup at the hospital, unless otherwise required by applicable law.
By signing below, I certify that the information provided is accurate to the best of my knowledge. I authorize the individuals listed above as described, accept financial responsibility for services provided, and acknowledge that I have read and understand the Outside Pharmacy Policy.
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New Client Information

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