New Patient Form

Welcome & Thank you for Choosing Wolfe Animal Hospital.The following information is required for your records and is strictly confidential.At Wolfe Animal Hospital, we are a service oriented profession and must have payment in full when services are provided or the patient is released from our hospital.We will gladly provide wellness or treatment plans with estimated fees so that you may plan financially for the care your pet may need. We accept Cash, Checks ( with identification) as well as all major Credit Cards and Care-credit. A $35.00 fee is charged for any returned checks in addition to the value of the check. A deposit is required for all patients being hospitalized. Any balance not paid in full or for returned checks may be subject to any additional charges incurred including finance charges, collection fees, attorney fees, and/or court cost if collection procedures are necessary. If I do not contact Wolfe Animal Hospital or neglect to pick up my pet within 5 days of departure/ discharge time, it will b assumed the animal is abandon and Wolfe Animal Hospital will attend to the situation as seen fit. I understand that this does not release me from my financial obligations, and I will still be responsible for my bill. By signing below, I assert that I am the owner or the authorized agent of the above described pet and agree to the terms indicated herein and agree to pay and assume all financial responsibility for he pet. I understand that total payment is due at the time of service is rendered and agree to the payment terms. I consent to the above named individuals authorizing treatment and understand that revision to this must be presented in writing. I understand that if any medical or surgical procedures are performed there may be risk involved and that it is not possible to guarantee the successful outcome of any procedure. I hereby authorize the veterinarian to examine, prescribe, treat and/or perform any necessary diagnostics for the above described pet. This agreement is in force indefinitely from this date forward unless I notify Wolfe Animal Hospital in writing to the contrary. I also authorize Wolfe Animal Hospital to use my pet(s photo should they select it to use in promotional material.

Owner's Name*

First NameLast Name

Owner's Date of Birth*

Date

Owner's Primary Phone Number*

Please enter a valid phone number.

Owner's Primary Email*

example@example.com

Owner's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Owner's Place of Employment

Spouse/Co-Owner's Name

First NameLast Name

Spouse/Co-Owner's Phone Number

Please enter a valid phone number.

Spouse/Co-Owner's Place of Employment

Emergency Contact

First NameLast Name

Emergency Contact Phone #

Please enter a valid phone number.

Pet's Name*

Pet's Species*

Pet's Breed*

Pet's Color*

Pet's Sex*

Pet's Date of Birth/Age*

Is this Pet currently on Monthly Heartworm Prevention*

YesNoIntermittently

Any medical or vaccination history pertinent to this pet?

Pet's Name

Pet's Species

Pet's Breed

Pet's Color

Pet's Sex

Pet's Date of Birth/Age

Is this Pet currently on a Monthly Heartworm Prevention

YesNoIntermittently

Any medical or vaccination history pertinent to this pet?

Pet's Name

Pet's Species

Pet's Breed

Pet's Color

Pet's Sex

Pet's Date of Birth/Age

Is this Pet currently on a Monthly Heartworm Prevention

YesNoIntermittently

Any medical or vaccination history pertinent to this pet?

Today's Date*

Date

Signature*

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