New Client Form Anthony Wayne

Owner Name*

First NameLast Name

Spouse / Additional Owner Name

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Primary Contact Phone*

Please enter a valid phone number.

Is this a cell phone or a home phone?*

CellHome

Secondary Contact Phone

Please enter a valid phone number.

Is this a cell phone or a home phone?

CellHome

Preferred contact method for appointment reminders:*

Phone CallText MessageEmail

Email

We value your personal information. Your email will only be used for notifications from Anthony Wayne Animal Hospital

What social media platforms do you use? (We are on FB and Instagram –awahospital)

FacebookTwitterInstagram

How did you hear about us?

If you were referred by a client, please tell us who so we can say thank you:

Pet's Name*

Pet Species*

DogCat

Pet Breed*

Pet Sex*

MaleNeutered MaleFemaleSpayed Female

Pet Coat Color*

Pet Age / D.O.B*

Are there any previous health issues?

Name of your previous veterinarian

Phone Number of your previous veterinarian

Please enter a valid phone number.

We love social media! We would like your consent to share your pet’s image on our social media and website. Your full name and personal information will never be used. Do you consent to this?*

Yes, please make my pet a star!No thank you, my pet is shy

If you must cancel an appointment, we ask for 24 hours notice. If cancelling a surgical appointment, we ask for 48 hours notice. A late cancellation or frequent cancellations may result in a fee being applied to your account.

Current vaccinations are required by Anthony Wayne Animal Hospital before we may admit any animal for any reason. These measures are taken to protect the well-being of all animals within our hospital.

Treatment Consent: I hereby authorize the veterinarian to examine, prescribe for or treat the above described pet (s). I assume responsibility for all charges accrued 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 exam and treatment. We will gladly prepare a written treatment plan of service fees if desired (please ask our receptionist, tech, or Dr.) For your convenience we accept Visa, Mastercard, Discover, Care Credit, and cash. Please stop at the reception desk to review and pay for services.

I confirm that the above information is correct and that I am the owner or authorized agent of the patient (s) listed above.

Signature*

Current Date*

Date

New Client Form

New Patient Information