New Patient Form

New Patient Form

Thank you for giving us the opportunity to treat your pets. We will be happy to answer any questions you have about your pet’s health. To ensure the best care possible, please take the time to fill in this form completely.
Tell us about You!
Name*

Last NameFirst Name
For check writing privileges, please provide your Driver’s License *
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Spouse*
Home*
Work*
Email address*
example@example.com
Emergency Contact Name*
Emergency Contact*
How did you learn of our clinic?*

Yellow PagesSignRecommendationOther
Tell us about your pet!
Pet’s Name*
Species*
Other
Breed*
Color*
Birthdate*

MonthDayYear
Sex*
Vaccine History
Date*

MonthDayYear
Type of Last Vaccinations*
Please check any symptoms or problems that you have noticed concerning your pet.*

VomitingBehaviorThirst IncreasedScootingScratchingDiarrheaBleeding GumsUrination IncreasedScratchingWeaknessCoughingBreathing ProblemsEye Bulging/BloodshotLimpingDepressedSneezingLack of AppetiteLoss of BalanceGaggingShaking HeadOther
Pet’s Current Medications*
Pet’s Current Diet*

Brand Nameany table food?
My signature below authorizes my pet’s records to be faxed/mailed/voiced over the phone to any kennel, boarding, grooming, adoption, or training facility that calls for records for the life of the pet. Medical information cannot legally be shared with such businesses without written authorization from the owner. If not initialed, our staff will not share information with these callers. As always, you can access your pet(s)’ information via your pet portal, you can pick up your records with valid photo ID, or you can have them mailed to the home address on file.
Owner signature*

Clear
I understand that photos of my pet(s) may be posted on Porter County Pet Clinic’s website,Facebook page, or Pet Portal Community page for advertising or promotional purposes.
Owner signature*

Clear
I hereby authorize the veterinarians to examine, practice for, or treat the above-described pet. I assume 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 and that a deposit may be required for admittance.
Authorization Signature*

Clear
Acceptable Methods of Payment

Cash, Check (with photo ID of person listed on check), Visa, MasterCard, Discover, AMEX or CareCredit
Should be Empty:

New Patient Form

Tell us about You!

Tell us about your pet!

Vaccine History

Acceptable Methods of Payment