Animal Hospital of Dunedin New Client Form

New Client Form
Welcome to the Animal Hospital of Dunedin

*=required
Client Information
Owner Name*

First NameLast Name
Spouse or Co-Owner

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Work Number
Please enter a valid phone number.
Cell Number*
Please enter a valid phone number.
Spouse/Co-Owner Number
Please enter a valid phone number.
Best Email*
example@example.com
Drivers License #
State
Is your address listed as a PO Box?

YesNo
Physical Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Pet Information
Pet Name*
Species*

CanineFelineGuinea PigHedgehogFerretHamsterRatMiceGerbilTurtleTortoiseBearded DragonBoa Constrictors/Pythons/Other Non-Venomous SnakeMini-pig
Breed*
Color*
Gender*

FemaleMale
Spayed/Neutered?*

YesNo
Birthdate or Approximate Age*
Microchip (If Applicable)
Current on Vaccinations?*

YesNo
History Provided?*

YesNoNot applicable
What hospital can we obtain them from? Hospital Name and Phone Number.
Additional Comments/Concerns
Current treatments, medications. Please list all medications and supplements including name, strength, and directions.
What is the presenting problem/complaint?
How old was your pet when the problem first started?
How has this problem changed?
What diet are you currently feeding your pet? Include treats as well.
Is your pet on flea and heartworm prevention?

YesNo
Has your pet had any herbal therapy or acupuncture previously?

YesNo
Are there any other pets in the household?

YesNo
If yes, what kind? (dog, cat, bird, reptile, other)
Has your pet been diagnosed with any other medical problem?
Is there any additional information that may be helpful?
Have you been referred to us by another hospital? If so which one.
Additional Information
How did you hear about us?

GoogleFacebookMailerWalked/Drove ByInternet - OtherOther HospitalExisting ClientCurrent EmployeeOther
If Internet, where?
Which Hospital?
Who May We Thank?
Which Employee?
If Other, Where?
Photo Consent
We love social media! Do we have your permission to share your pet(s)' image and story on social media, our website, and other forms of related media? Your name and personal information will never be shared. Simply check below to authorize this.*

Yes. I authorize AHOD to share my pet's story and photo.No. I do not authorize this.
ScribbleVet Consent and Release
Our veterinary services utilize ScribbleVet, a tool from Kairo Care, Inc., which records your pet's appointments for improved clinical documentation. We need your consent to proceed with the recording.

By signing this agreement:
1. Appointment Recording: You agree that your vet appointments may be recorded. If you don't want to be recorded, let us know.

2. Usage Rights: You grant us permission to share these recordings, and any other materials you choose to provide, for the purpose of improved clinical documentation.

3. Age Confirmation & Understanding: You affirm that you are at least eighteen years old, and that you understand and accept the terms in this agreement.

We are committed to providing the best care for your pet in a manner comfortable for both of you.
Treatment Consent

I hereby authorize the veterinarian to examine, prescribe for or treat the above-described pet(s). I assume responsibility for all charges incurred in the care of this animal. I understand that payment is always due IN FULL at the time of service and that a deposit may be required for hospitalization and surgical procedures. I recognize that financial concerns should be discussed PRIOR to exam and treatment. The AHOD staff is happy to provide estimates.I understand that the Animal Hospital of Dunedin does not bill. Acceptable methods of payment are cash, check, Visa, MasterCard, American Express, Discover, and CareCredit. I also understand that if my account is not paid in full that I will be liable for a monthly finance charge of 1.5% and any fees that may be incurred for the services of an outside collection agency.
Client's Signature*

Clear
Today's Date*

MonthDayYear
Date
Should be Empty:

New Client Form

Welcome to the Animal Hospital of Dunedin

Client Information

Pet Information

Additional Information

Photo Consent

ScribbleVet Consent and Release

Treatment Consent