Hamburg VC-New Client/Patient Intake Form

New Patient Registration Form
Primary Owner

First NameLast Name
Phone Number
Please enter a valid phone number.
Co-Owner

First NameLast Name
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Pet Information
Pet's Name
Date of Birth

MonthDayYear
Date
Breed
Color
Species (select one)
Gender (select one)
Pet Origin (select one)

Rescue/ShelterBreederPet StoreFamily/FriendOther
If Other, please list here
Pet History
Current Medications (including over the counter)*
If your pet has a microchip for identification, please provide the number below.
Previous surgeries/medical procedures:*
Does your pet have any known allergies to food or medicaiton?*

YESNO
If yes, please list the food or medication(s) that your pet is allergic to.
Previous Vet Hospital Name*
Previous Vet Hospital Phone Number
Please enter a valid phone number.
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.

Cancelof
If you did not upload your pet's records here, you can also email or fax them to the hospital. Email: hamburgvet@ptd.net or Fax: 973-827-8345
How did you hear about us?*
Ocassionally 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?

YesNo
I certify that I am the owner of the above pet and that all information is accurate. I am responsible for payment to Hamburg Veterinary Clinic for all treatment given to my pet. We accept cash, 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. Please sign below to accept these terms.*

Clear
Date*

MonthDayYear
Date
Should be Empty:

New Patient Registration Form

Pet Information

Pet History