New Patient Registration

New Patient Registration
New Client/New PatientCurrent Client/ New Patient
Name*

First NameLast Name
Spouse/Co-Owner

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Spouse/Co-Owner Phone Number

Area CodePhone Number
Email Address *
example@example.com
How did you hear about us?*
Pet Insurance Company
Policy #
Pet Name*
Species*
Breed*
Date of Birth *

MonthDayYear
Date
Color/Markings *
Sex*
Spayed/Neutered*
Microchip ID #
Previous Veterinarian
Previous Veterinarian Phone Number

Area CodePhone Number
Previous Medical History

Browse Files
Click to Attach Previous Medical Records Cancelof
Social Media Authorization*

YES I give Linwood Animal Hospital consent to post my pet on social media.NO I do not give Linwood Animal Hospital consent to post my pet on social media.
PLEASE READ:

Payment is required at the time services are rendered unless other arrangements are made in advance with our hospital manager.

Forms of payment accepted: Cash, Check, VISA, Master Card, Discover, Care Credit and Scratchpay.

I understand that I am financially responsible to Linwood Animal Hospital for all charges. I further agree, in the event of non-payment, to bear the cost of collection and /or court cost and reasonable legal fees should this be required, at an interest
rate of 1.5 % per month (18% APR).

I authorize that I am at least 18 years of age and able to make financial decisions for my animal(s).

I hereby authorize Linwood Animal Hospital to prescribe for and treat the animal(s) presented by me. The hospital and staff will not be held liable for any problems that develop provided that reasonable care is exercised.

In the event my animal is hospitalized, and I cannot be reached for more than five (5) days, my animal(s) shall be considered abandoned and Linwood Animal Hospital has complete authority to re-home/euthanize the animal as deemed best by hospital staff. This however does not relieve me from any financial obligation, and legal action may be taken to obtain payment.
Acknowledgement*

I have read and agree to all of the statements outlined above. (Required)
Date*

MonthDayYear
Date
Should be Empty: