New Client Form (Custom PDF update 3.3.21)

New Client Form
Download our app before your visit! Once you submit this form and your chart is made in our system you will be able to create an account using the email address you provide below.
Date of Appointment

MonthDayYear
Date
Time of Appointment

Hour Minutes

AM/PM Option
Owner's Name*

First NameLast Name
Owner's Cell Number*
Please enter a valid phone number.
Owner's Home Number
Please enter a valid phone number.
Secondary Contact Name

First NameLast Name
Secondary Contact Number
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
How did you hear about us?*

Current ClientDriving/ Walking bySocial MediaReceived a MailerOnline SearchOther
If referred by a current client, please tell us who so we can say thank you!
We know there are a lot of veterinary options for you and we are so glad you chose us! We would love to know why you chose us:*
Pet's Name (1)*
Species (1)*

CanineFelineOther
Sex (1)*

Spayed FemaleFemaleNeutered MaleMaleUnknown
Breed (1)*
Color (1)*
Age/ Date of Birth (1)*
Microchip Number (1)*
Name and contact of your previous veterinarian? (1)*
May we contact them for records?*
How long have you had your pet?*
How did you acquire your pet? (1)*

Shelter/ RescueBreederFriend or Private PartyFoundI'm FosteringOther
Do you have documentation showing a transfer of ownership? (1)*

Yes (Please attach documents along with any medical records below)No
We recommend filling out a transfer of ownership form with the previous owner and attaching the document below with any previous medical records you may have (1)
Where/ when did you find this pet? (1)*
(1) If you have not already done so, we recommend utilizing these resources to try and locate the owner:

Shelter At Home

PawBoost

Pasadena Humane - Found Animal
What is the name of the rescue organization? (1)*
Do you have another pet to add?*

YesNo
Pet's Name (2)*
Species (2)*

CanineFelineOther
Sex (2)*

Spayed FemaleFemaleNeutered MaleMaleUnknown
Breed (2)*
Color (2)*
Age/ Date of Birth (2)*
Microchip Number (2)*
Name and contact of your previous veterinarian? (2)*
May we contact them for records? (2)*
How long have you had your pet? (2)*
How did you acquire your pet? (2)*

Shelter/ RescueBreederFriend or Private PartyFoundI'm FosteringOther
Do you have documentation showing a transfer of ownership? (2)*

Yes (Please attach documents along with any medical records below)No
We recommend filling out a transfer of ownership form with the previous owner and attaching the document below with any previous medical records you may have (2)
Where/ when did you find this pet? (2)*
(2) If you have not already done so, we recommend utilizing these resources to try and locate the owner:

Shelter At Home

PawBoost

Pasadena Humane - Found Animal
What is the name of the rescue organization? (2)*
If you have another pet to add please fill out an additional form
If you have any digital medical records please attach them here. If you have paper records you could always take well lit photos of them with your phone and upload those as well!

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Our veterinary team is committed to our values of Empathy, Compassion, Understanding and Open Communication. We ask that you partner with us and share in these values. We will not tolerate yelling, swearing or any type of abuse to our team. If something is not right, we want to help address it, in a respectful manner.

Sincerely, The Doctors and Team at Crescenta Cañada Pet Hospital

I confirm that the above information is correct and that I am the owner or authorized agent of the patient listed above. I now authorize the veterinarian to examine, prescribe for, and treat the above-described pet. I assume responsibility for all charges incurred in the care of this animal. I understand that payment is always due in full at the time of service. I recognize that financial concerns should be discussed prior to the exam and treatment. For your convenience, we accept credit cards, Care Credit, cash, and checks with proper identification.

By signing below I consent to automated and/or manual communications in relation to appointment confirmations, medical reminders, and payment requests via mail, text, email, calls, and voicemail. I understand that I may opt out of some, but not all, forms of communication as it relates to my pet's health.
By signing below, I acknowledge and consent to audio recordings made during my pet’s appointment and physical examination to aid inaccurate medical record keeping. These recordings will be stored in accordance with applicable laws and privacy standards. *

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