St. Francis Animal Hospital - New Patient Form

New Patient Information
Name*

First NameLast Name
She/herHe/himThey/themOther (please write your pronouns here)
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Partner's Name (if applicable)

First NameLast Name
She/herHe/himThey/themOther (please write your pronouns here)
Partner's Phone Number (if applicable)
Please enter a valid phone number.Format: (000) 000-0000.
YesNo, I have had pets who have been seen at St. Francis previously or who are current patients of St. Francis.
I am a current client.Referred by:
Who referred you to St. Francis Animal Hospital?*
Pet Information
Pet's Name*
Pet's Date of Birth or Age (please note if this is an estimate)*
CanineFelineRabbitGuinea PigFerretRatMouseHedgehogChickenDuckOther
Breed*
Color*
MaleFemaleUnknown
Humane Society or RescueBreederPrivate adoption (i.e. via Craigslist, rehomed from a friend or family member)Pet storeOther (please list)
What is {petsName}'s primary diet?*
Please include brand and amount fed, i.e. Purina Sensitive Skin and Stomach, 1/2 cup twice a day
YesNoUnknown
Does {petsName} have medical records at another veterinary clinic? If so, please list the clinic(s) so we can contact them for your pet's records.*
Does {petsName} have any past pertinent medical history that you'd like us to be aware of?*
Clinic Policies
If you are a new client at St. Francis Animal Hospital, please note that you must be present at your pet/pets' first visit to our clinic. Pets should not be brought in for their first exam to establish care by a petsitter, a minor, or anyone other than a primary owner.

Payment is due at the time services are rendered. We do not offer payment plans, but we do offer the following options for payment:
- Cash
- Check
- Credit Card (Visa, Mastercard, American Express, and Discover)
- Apple Pay
- Google Pay
- Care Credit
Yes, I have read and agree to abide by the above policies.I have read the above but need further clarification (**A staff member will call you to discuss further.**)
Consent to Take Photos
We may take photos of our patients for many reasons, such as documentation of medical conditions (i.e. skin lesions), photo updates for owners following surgical procedures, or educational photos. Unless specifically discussed with you, these photos are a confidential part of your pet's medical records. Please initial below if we have consent to take photos of your pet.*
If you do not consent, please write "Declined"
Consent to Share Photos
We love to share photos of our patients via social media! Initialing below indicates that you consent to allow St. Francis Animal Hospital to use photographs of your pet for any lawful purpose, including publicity, illustration, and advertising on our website, Facebook, Instagram, YouTube, and other social media platforms. Please initial below if we have consent to share photos of your pet.*
If you do not consent, please write "Declined"
Google searchGoogle MapsOnline reviewsCinic websiteFacebookInstagramReferred by a friend/family memberReferred by another veterinarianReferred by a rescue/shelterDrove by/saw clinic signOther (please specify)
Who referred you?
Should be Empty:

New Patient Information

Pet Information

Clinic Policies

Consent to Take Photos

Consent to Share Photos