Pinehurst Animal Hospital & Dental Clinic

Pinehurst Animal Hospital & Dental Clinic

Pinehurst Animal Hospital & Dental Clinic

Tony Ioppolo, DVM - Pamela Means, DVM - Dana FitzGerald, DVM - Tracy Wilkinson, DVM
NEW CLIENT FORM

Please make sure to FULLY complete form PRIOR to the day of your appointment. Failure to provide New Client Form and Full Medical Records prior to appointment may result in appointment being seen as a work in which will include a wait time.
195 Dr. Neal Road - Southern Pines, NC 28387

Office: (910) 692-3551

Email: info@pinehurstvet.com

Website: www.PinehurstVet.com
Today's Date

MonthDayYear
YesNo
Email (It will not be given out, it is to send invoices and reminders)
example@example.com
Name*

PrefixFirst NameLast Name
Account Holders Birthday *

MonthDayYear
(required for medications)
Spouse's Name

First NameLast Name
Mailing Address*
City*
State*
Zip*
Home
Cell*
Work Phone
Enter if you can be contacted here
Spouse's Cell Phone
If Recommended, by whom? We appreciate referrals and we will be sure to thank the one who referred you to us with a special certificate!
If Recommended, by whom?
First and Last Name
Patient Information
Pet's Name*
Date of Birth / Approximate Age*
Species*
Breed*
Color*
Male (Intact)Male NeuteredFemale (Intact)Female Spayed
Is your pet microchipped? If so, please enter their microchip number.
Any previous serious illness or injury?*
Any allergies to vaccines or medications?*
Previous Vet Clinic Name and Contact Information: We will call to have your records emailed PRIOR to your appointment (IF YOUR RECORDS ARE UNDER A DIFFERENT NAME, PLEASE PROVIDE THIS AS WELL)*
- Pet's Name
- Species
- Date of Birth / Approximate Age
- Breed
- Color
- Male (Intact)Male NeuteredFemaleFemale Spayed
- Is your pet microchipped? If so, please enter their microchip number.
- Previous Vet Clinic Name and Contact Information: We will call to have your records emailed PRIOR to your appointment (IF YOUR RECORDS ARE UNDER A DIFFERENT NAME, PLEASE PROVIDE THIS AS WELL)
- Any allergies to vaccines or medications?
- Any previous serious illness or injury?
- Do you already have Full Medical History?
  Records are needed prior to making an appointment.
- Pet's Name
- Species
- Date of Birth / Approximate Age
- Breed
- Color
- Male (Intact)Male NeuteredFemale (Intact)Female Spayed
- Is your pet microchipped? If so, please enter their microchip number.
- Previous Vet Clinic Name and Contact Information: We will call to have your records emailed PRIOR to your appointment (IF YOUR RECORDS ARE UNDER A DIFFERENT NAME, PLEASE PROVIDE THIS AS WELL)
- Any allergies to vaccines or medications?
- Any previous serious illness or injury?
- Do you already have Full Medical History?
  Records are needed prior to making an appointment.
- Pet's Name
- Species
- Date of Birth / Approximate Age
- Breed
- Color
- Male (Intact)Male NeuteredFemale (Intact)Female Spayed
- Is your pet microchipped? If so, please enter their microchip number.
- Previous Vet Clinic Name and Contact Information: We will call to have your records emailed PRIOR to your appointment (IF YOUR RECORDS ARE UNDER A DIFFERENT NAME, PLEASE PROVIDE THIS AS WELL)
- Any allergies to vaccines or medications?
- Any previous serious illness or injury?
- Do you already have Full Medical History?
  Records are needed prior to making an appointment.
- Yes (Please enter Appointment date in "OTHER")No.Other
- Authorization
- Pinehurst Animal Hospital requires payment in full and is expected at the time services are rendered. We will be happy to give you an estimate before any charges are incurred, just let us know. I hereby authorize the Veterinarian to examine, prescribe for and/ or treat my pet(s). I assume responsibility for all charges incurred in the care of my animals. Also, I understand that these charges will be paid in full at the time of release and that a deposit may be required for surgical treatment. I understand if I have an unpaid balance to Pinehurst Animal Hospital and do not make satisfactory payment arrangements, my account my be placed with an external collection agency. I will be responsible for reimbursement of the fee of any collection agency, which may be based on a percentage at the maximum of 35% of the debt, and all costs and expenses, including reasonable collection and attorney’s fees incurred during collection efforts. In order for Pinehurst Animal Hospital or their designated external collection agency to service my account, where not prohibited by applicable law, I agree that Pinehurst Animal Hospital and designated external collection agency are authorized (I) contact me by tele-phone at the telephone number(s) I am providing, including wireless telephone number , which could result in charges to me, (II) con-tact me by sending text messages (messages and data rates may apply) or emails, using any email address I provide and (III) methods of contact may include using pre–recorded/ artificial voice message and/ or use of any automatic dialing device, as applicable.
- Payment options: Cash, Check, American Express, Mastercard, Visa, Discover, Care Credit
- Signature
  
  Clear
- Should be Empty: