North Station - New Client Form

Boston Animal Hospital @ North Station

102 Beverly St | Boston, MA | 02114
New Client Form
Primary Owner*

First NameLast Name
Primary Phone Number*
Primary Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Secondary Owner

First NameLast Name
Secondary Phone Number
Secondary Email
example@example.com
Preferred method(s) of communication:

EmailCallText
How did you hear about Boston Animal Hospital? (e.g. friend, Google search, advertisement...)
Pet Information
Name*
Species*

DogCat
Sex*

MaleMale - NeuteredFemaleFemale - Spayed
Date of birth or Estimated age (if DOB unknown)*
mm/dd/yyyy
Breed*
Color
Microchip
Where else have you brought your pet? (e.g. previous veterinary clinic(s), emergency centers, specialty hospitals, etc...)*
Previous Medical Records*

*This is required prior to your pets' appointment. If you do not have access to your pets' documents at this time, please submit their documents via email at staff@bostonanimalhosp.com or fax to 617-427-2215
Cancelof
Social Media Release
Our hospital frequently posts pictures and/or videos of our patients on Instagram and Facebook and/or other social media platforms:

I grant permission to Boston Animal Hospital, its employees and authorized representatives to take photographs and/or videos of me and/or my pet(s), to copyright, use and publish the same in print and/or electronically. Boston Animal Hospital may also use and public, my pet’s story, including relevant medical history. I agree that Boston Animal Hospital may use such photographs, videos, or stories including me and/or my pet with or without our names and for any lawful purpose, including social media, publicity, advertising, and other web content.
Authorization*

Yes, I consentNo, I do not consent
Treatment and Payment Agreement
I hereby authorize the veterinarian to examine, prescribe for and/or treat the above described animal. I assume full responsibility for all charges incurred in the care of this animal. I also understand that these charges will be paid at the time of release. I am aware of BAH’s deposit policy and I will be able to provide a deposit for any examinations, surgical procedures, and/or additional hospitalized treatment.
Authorizer*

First NameLast Name
Should be Empty:

Boston Animal Hospital @ North Station

New Client Form

Pet Information

Social Media Release

Treatment and Payment Agreement