New Patient Registration Form
Please provide us with a copy of your pet's current medical records. You may attach them below or email a copy to customer.care@ahdcvets.com.
Owner's Name:
*
First Name
Last Name
Phone Number:
*
-
Area Code
Phone Number
Patient's Name:
*
Species:
*
For Example: Cat, Dog, Bird, Etc.
Breed:
*
If unsure, please type "Unknown".
Color(s):
*
Age:
*
Date of Birth:
*
If unknown, please use an approximation.
Length of Time Owned:
*
Patient's Medical History
Previous Animal Hospital:
*
If the pet as never been seen prior, please type "None".
Previous Veterinarian:
*
If the pet has never been seen prior, please type "None".
Sex
*
Male
Female
Is your pet spayed or neutered?
*
Yes
No
Microchip Number
*
If your pet does not have a microchip, please type "N/A".
Does your pet have Pet Insurance?
*
Yes
No
If yes, with which company do you hold a policy?
*
If your pet does not have Pet Insurance, please type "N/A".
Date of Last Exam:
*
If your pet has not been seen prior, please type "N/A".
Date of last Rabies Vaccine:
*
If your pet has not been vaccinated for this prior, please type "N/A".
Date of last Distemper Vaccine:
*
This could be listed as DAPP, DALPP, DHPP, or DHLPP. If your pet has not been vaccinated for this prior, or is not a dog, please type "N/A".
Date of last Lyme Vaccine:
*
If your pet has not been vaccinated for this prior, or is not a dog, please type "N/A".
Date of last FVRCP Vaccine:
*
If your pet has not been vaccinated for this prior, or is not a cat, please type "N/A".
Date of last FeLV Vaccine:
*
If your pet has not been vaccinated for this prior, or is not a cat, please type "N/A".
Is your pet on Flea/Tick Prevention?
*
Yes
No
If yes, please list the brand and last given date:
Is your pet on Heartworm Prevention?
*
Yes
No
If yes, please list the brand and last date given:
Please go back to the New Client Center to Upload your pet(s)' medical records, after submitting this form.
We pledge to do our very best to care for your pet's health needs. In return we ask you to accept the responsibility for charges incurred in the treatment of your pet. Payment is required at the time services are rendered. We accept all major credit cards, cash, checks, and CareCredit. We may also require deposits for certain services. By signing this form, you agree to pay for all charges incurred in the care of this pet.
*
AHDC Appointment Cancellation Policy: No-Show Appointment Policy: A No-Show Appointment is when a client fails to be present at their scheduled appointment time without a phone call, text, or email within at least 24 hours of a scheduled appointment. A $50.00 fee will be added to accounts for existing clients who do not show for scheduled appointments and an invoice will be sent via email on file. The full obtained deposit for new clients will be forfeited for those who do not show for scheduled appointments. By signing this form, you agree to our appointment cancellation policy.
Date of Signature:
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: