New Client & Patient Form

New Client & Patient Form

Welcome to Brandon Animal Hospital! We look forward to meeting you and your pet!
Your Information
Your Name*

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

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Employer
Driver's License: State License Number
Secondary Contact / Significant Other

First NameLast Name
Secondary Contact PhoneNumber
Please enter a valid phone number.
Preferred Contact Method(s)*

PhoneTextE-mailSecondary Contact
Your Pet's Information
Name of Pet*
Species*

DogCat
Sex*

Spayed FemaleIntact FemaleNeutered MaleIntact MaleUnknown
Date of Birth -or- Approximate Age*
Breed*
Color / Description*
Does your pet have a Microchip?*

YesNoUnknown
Microchip Number
Does your pet have Insurance?*

YesNo
Pet Insurance Information:
Do we need to contact you to schedule an appointment for your pet?*

Yes, please contact me.No, I will contact you when I'm available.No, my pet already has an appointment scheduled.
Reason for appointment.*
If your pet is sick or needs to be seen urgently, please contact our front desk at (540)345-8486.
Photo of Pet

Cancelof
Medications your pet currently takes. Please include dose and frequency of administration.
Other veterinary clinics which may have pertinent information about your pet, such as vaccine certificates, lab work or medical history.
Medical Record Upload

Cancelof
Account Authorization
Brandon Animal Hospital Hours of Operation*

By checking this box I (Client of Brandon Animal Hospital) I understand that Brandon Animal Hospital hours of operation are as follows: Weekdays, Monday through Friday 8 AM to 6 PM and Saturday, 8 AM to 12 Noon. Brandon Animal Hospital is closed on Sundays and Holidays. Brandon Animal Hospital has no in-house, on-duty, continuous medical staff care: 1. Weekday overnights, from close-of-business at 6 PM until 8 AM; 2. Weekend overnights, from close-of-business at 12 noon on Saturday until Monday at 8 AM; 3. Holidays, from close-of-business the day before the holiday until 8 AM the following day.
Brandon Animal Hospital Payment and Billing Policy*

By checking this box I (Client of Brandon Animal Hospital) authorize Brandon Animal Hospital to examine, diagnose, prescribe for and/or treat my pets. I assume full responsibility for all charges incurred for the care of my pets. I understand that charges will be paid at the time of release and that a deposit may be required for surgical treatment or hospitalization. I understand that a written estimate for any services can be provided upon request. I understand that any unpaid charges are subject to any applicable billing fees, collection costs, monthly interest of 1.5% (18% /annually) and may be referred to a collection agency or attorney.
Payment is expected at time of service, What is your preferred payment method?

CashCheckCard (Visa/ Mastercard/ Discover)ScratchPay (Additional 5% Fee)
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

New Client & Patient Form

Your Information

Your Pet's Information

Account Authorization