NEW CLIENT INFORMATION

Owner Name*

First NameLast Name

Phone Number*

Area CodePhone Number

Email*

example@example.com

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Spouse/Other

First NameLast Name

Spouse/Other Phone Number

Area CodePhone Number

How did you hear about us?*

If you were referred, who may we thank?

Pet's Name*

Pet's Date of Birth or Approximate Age*

Species*

DogCatOther

Sex*

Breed*

Color*

Date of most recent vaccines and where were they given?

Is your pet on any routine medications? If so what?*

Is your pet on flea or heartworm prevention? If so what? *

To your knowledge, does your pet have any allergies? *

Do you grant permission for Hog Mountain Animal Hospital to take photos of my pet(s) and use for any lawful purpose, including, publicity purposes, illustration, advertising, and web/social media content?*

YesNo

Payment Policy

Payment is due at the time of service. We accept cash, checks, care credit, Visa, MasterCard, Discover, American Express, and debit cards. All unpaid balances will incur a 1.5% finance charge at the end of each month. All returned checks will incur a $35.00 service charge.

Medical and Surgical Release

By submitting this online form, I hereby consent and authorize Dr. Martinez, Dr. Britt, or any other doctor employed by Hog Mountain Animal Hospital to receive, prescribe for, and treat my pet/pets.

Boarding Policy

We offer boarding facilities for your pets. For your pet's protection, we do require that all boarders be up to date on core vaccines and labs, including rabies, DHPP, bordetella, and an intestinal parasite exam for dogs, and rabies and FVRCP for cats. In the event that your pet should become ill while under our care, we will take all necessary emergency action. We will make every effort to contact you. We ask that you leave an emergency phone number each time that you board your pet. Boarding charges begin on the day that the pet is brought in and continue each day until the day of pick-up. If the pet is picked up before noon or is being groomed/bathed on that day, there will be no boarding charge on the last day. If your pet is seen by a doctor, we may call you to discuss the exam unless you specify otherwise. If any fleas, ticks, or other parasites are observed, that pet will be treated for these parasites at the owner's expense.

I hereby agree to the above Payment Policy, Medical and Surgical Release Policy and Hospital Policy. I will not hold Hog Mountain Animal Hospital, the veterinarians, or any staff member liable for any complications that may arise. Please select yes to indicate that you understand and agree with the above information.*

YesNo

Signature*

Signing this form means you agree to the above policies