Orange Veterinary Hospital New Client/Patient Registration Form

New Patient Registration Form

***PLEASE COMPLETE WITHIN 48 HOURS OF MAKING APPOINTMENT***
Primary Owner *

First Name Last Name
Cell Phone Number *
Please enter a valid phone number.
Co-Owner

First Name Last Name
Co-Owner Cell Phone Number
Please enter a valid phone number.
Current Home Address *

Street Address

Street Address Line 2 (Apartment floor, Unit number, etc.)

City State / Province

Postal / Zip Code
Primary Email *
example@example.com
How did you hear about our hospital? Select all that apply.
If you were referred to OVH from an existing client of our hospital, please share their name with us so we can thank them!

First Name Last Name
Pet Information
Pet's Name *
Date of Birth or Approximate year *

Month Day Year
Date
Breed *
Color *
Species (select one) *
Gender (select one) *
Pet Origin

Rescue/Shelter Breeder Family/Friend Safari Stan's Pet Center Another Pet Store (A-Z Pets, All Pets Club, etc.) Other
If Other, please list here:
Pet History
Current Medications (including over the counter) *
Previous surgeries/medical procedures: *
Previous Vet Hospital Name *
Name of hospital/clinic your pet has received their most recent veterinary care.
Previous Vet Hospital Phone Number *
Please enter a valid phone number for contact.
Do we have permission to contact this hospital to obtain records on your behalf? *

Yes, please! No, I will call myself/Send records myself
Please upload any of your pet's previous vaccination information or medical records here and they will be sent directly to the hospital with this completed form.

Cancel of
If you are unable to upload your pet's records here, you can also email or fax them to the hospital.

Email: hello@orangevets.com Fax: 203-799-7032

Pictures or .JPEG images are sufficient!
Occasionally we use photos of clients' pets on our Facebook and Instagram without using last names. Do we have your permission to use your pet's photo on our social media sites?

Yes No
I certify that I am the owner of the above pet and that all information is accurate. I am responsible for payment to Orange Veterinary Hospital for all treatment given to my pet. We accept cash, checks, American Express, MasterCard, Visa, and Discover. For your convenience, we have partnered with Care Credit for all billing services. Please note payment is required at the time of services rendered. To prevent the spread of infectious diseases, all boarders, grooms, and hospitalized pets MUST be current on all core vaccines. A signature below authorizes this level of preventative care and your responsibility for payment of appropriate charges. AS OF MAY 2022, WE HAVE IMPLEMENTED A NO SHOW/NO CALL FEE OF $50- please give us a fair 24 hour advanced notice if you need to cancel or reschedule your pets appointment.

Clear
Date *

Month Day Year
Date
Should be Empty:

New Patient Registration Form

Pet Information

Pet History