New Client Information Form

Owner/Primary Account Holder Name*

First NameLast Name

Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Primary Phone Number*

Please enter a valid phone number.

Primary Email Address*

example@example.com

Please note that any individuals, and only the individual(s) listed as Secondary Account Holders can make medical and/or financial decisions on your behalf and will be granted full access to the account until we are notified in writing otherwise.

Spouse/Significant Other (Secondary Account Holder)

First & Last NameRelationship

Would you like to add anyone else as an Secondary Account Holder?

First & Last NameRelationship

Spouse/Significant Other (Secondary Account Holder) Phone

Please enter a valid phone number.

Spouse/Significant Other (Secondary Account Holder) Email

This will NOT be the primary email address on file

How did you hear about us?*

If this was a personal or professional referral, who can we thank?

First & Last Name or Business Name

Pet's Name*

Pet's Species*

CatDog

Pet's Date of Birth or Estimated Age*

ie: 1/24/2010 or 11y

Pet's Breed & Color(s)/Marking(s)*

ie: Lab mix, black w/ white feet & chest

Pet's Sex*

MaleFemale

Spayed/Neutered?*

YesNo

Any known allergies to medications or vaccines? If so, please explain:*

Any serious or major medical concerns of which we should be aware? If yes, please explain:*

Second Pet's Name

Pet's Species

CatDog

Pet's Date of Birth or Estimated Age

ie: 1/24/2010 or 11y

Pet's Breed & Color(s)/Marking(s)

ie: Lab mix, black w/ white feet & chest

Pet's Sex

MaleFemale

Spayed/Neutered?

YesNo

Any known allergies to medications or vaccines? If so, please explain:

Any serious or major medical concerns of which we should be aware? If yes, please explain:

Prior to your first appointment date, please remit your pet's medical history and/or breeder adoption records to info@belmontanimalhospital.com (include yourname and your pet's name in the subject) and provide the name, city and state of the veterinary practice that has medical records for your pet(s). If your pet has visited more than one, please separate them by a | in the fields below.

Name of Veterinary PracticeCity & State of Veterinary Practice

If the name provided above does not match the name on the account with the other veterinary practice(s) please indicate the other account-holder-name so we can ensure your pet's records are properly synced with your pet's chart.

First & Last Name

I authorize Belmont Animal Hospital, its authorized representatives and employees, to take pictures, photographs, film or video recordings, audio recordings, digital images, personal recollections, medical case synopses, radiographs and the like (collectively, "Pictures & Stories") of my pet(s) and my property in connection with the aforementioned pet(s). I authorize Belmont Animal Hospital, its assignees and transferees to copyright, use and publish the same in print and/or electronically. I agree that Belmont Animal Hospital may freely use such Pictures & Stories of my pets(s) for any lawful purpose, including but not limited to publicity, illustration, advertising, public education, web content and social media posting.*

YesNo

Patients will be seen in the following order: Emergencies, On-time Appointments, Work-ins.

Any appointments arriving 10 or more minutes late will lead to that appointment being worked in between our on-time appointments whenever possible, which will incur an increase in the office visit of no more than $25. Depending on our patient load at that time, it may result in extended wait times or our offering to reschedule the appointment for a future date.

Any appointments needing to be cancelled or rescheduled should be done at least 24 hours in advance to provide the opportunity for pets on a waiting list to use that appointment time.

By signing below, you state that you have read, been granted the opportunity to ask questions, understand and agree to the following: All of the information provided herein is true and accurate to the best of my knowledge. I state that I am the owner and responsible party (Account Holder) for the animal(s) listed above and that I, and other individuals listed above (Secondary Account Holder(s)), have the decision-making authority regarding the care and treatment of the animal(s) and any future animals; decisions for which I shall be financially responsible. I understand that I may revoke the decision-making authority for any Secondary Account Holder(s) at any time by submitting the revocation request in writing to Belmont Animal Hospital. I agree that I will treat Belmont Animal Hospital's employees and/or representatives with respect and understand that verbal abuse, threats of violence and acts of hostility will not be tolerated. I agree to abide by Belmont Animal Hospital's current Appointment Attendance Policy. I grant Belmont Animal Hospital full authority to release my animal(s)' medical records to partner veterinary medical facilities to include but not limited to specialty and/or referral hospitals when deemed by the attending veterinarian to be in the best interest of the animal(s). I also grant Belmont Animal Hospital to remit my animal(s)' vaccination status, current or not, to a requesting boarding/grooming/daycare facility and understand that I may revoke these authorizations at any time by submitting the revocation request in writing to Belmont Animal Hospital.

Signature of Owner / Account Holder*

Today's Date*

Date

New Client Information Form

The Human(s)

The Pet(s)

Love pets as much as we do and have more than two? Ask one of our Client Services Representatives for an extra page!

Social Media Release

Appointment Attendance Policy