New Client Questionnaire

New Client Questionnaire

Please use the below form for all New Clients and Patients. Please note that as of October 1st, 2024, we are unable to accommodate Avian patients. Thank you!
Today's Date*

MonthDayYear
Date
Your Name:*

First NameLast Name
Your Spouse or Partner:

First NameLast Name
Address: *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone Number:*
Please enter a valid phone number.
Secondary Phone Number:
Please enter a valid phone number.
Emergency/Secondary Contact:

First NameLast Name
Relationship To Owner:
Emergency/Secondary Phone Number
Please enter a valid phone number.
Is your Emergency/Secondary contact allowed to make medical decisions regarding your pet(s) health should you be unreachable?

YesNo
Your E-Mail Address:*
example@example.com
Previous Veterinarian:

First Pet Information
Pets Name:
Species:

DogCatPocket Pet (Hamster, Rabbit, Guinea Pig, etc.)Exotic (Bearded Dragon, Ball Python, etc.)
Breed:
Date of Birth (or approximate age):
Gender:

Male - IntactMale - NeuteredFemale - IntactFemale - Spayed
Color:
What type of diet does your pet eat?:
Is your pet on any medications? If yes, please explain:
Do you have any immediate medical concerns for your pet?
Do you have any medical history you would like to include?:

Cancelof

Second Pet Information
Pets Name:
Species:

DogCatPocket Pet (Hamster, Rabbit, Guinea Pig, etc.)Exotic (Bearded Dragon, Ball Python, etc.)
Breed:
Date of Birth (or approximate age):
Gender:

Male - In TactMale - NeuteredFemale - In TactFemale - Spayed
Color:
What type of diet does your pet eat?:
Is your pet on any medications? If yes, please explain:
Do you have any medical history you would like to include?:

Cancelof

Third Pet Information
Pets Name:
Species:

DogCatPocket Pet (Hamster, Rabbit, Guinea Pig, etc.)Exotic (Bearded Dragon, Ball Python, etc.)
Breed:
Date of Birth (or approximate age):
Gender:

Male - In TactMale - NeuteredFemale - In TactFemale - Spayed
Color:
What type of diet does your pet eat?:
Is your pet on any medications? If yes, please explain:
Do you have any medical history you would like to include?:

Cancelof

Northside Animal Hospital Payment Policies
Payment is expected at the time of service. In order to focus on our patients’ needs, customer service, and minimizing costs – we no longer offer billing services or payment plans. We accept cash, debit cards and credit cards including Visa, Mastercard, or Discover. We do not accept American Express. All cards must be signed by the owner of the card. Due to recent policy changes, checks are no longer accepted. We do offer the option of pre-paying for visits of procedures. We are happy to add a credit onto your account prior to your pet’s visit. Many times, this can help offset any unexpected costs. For payment assistance, we encourage clients to consider Care Credit or Scratch Pay.
By checking this box, you agree to the Northside Animal Hospital Payment Policies.*

I agree
Pet Insurance
Another popular option for your family and pet is to consider pet insurance. At Northside Animal Hospital, we highly recommend and encourage insurance as a way to provide payment assistance for unexpected expenses. Payment is expected at the time of service, and insurance claims are the responsibility of the pet owner to submit. We recommend looking into Pawlicy Advisor to learn what Insurance may be best for you and your pet.
Kindness Pledge
Our Pledge To you:
- We pledge to lead our practice with kindness and compassion.
- We will take responsibility for our actions and do our best to educate ourselves for the better of others.
- We understand that in making everyone feel included, we will need to speak up but not over others.
- We pledge to stand up against transphobia, homophobia, racism, ableism, sexism, and xenophobia.
Your Pledge to Northside Animal Hospital:
- I promise to raise any concerns about the cost of my pet's care in a respectful manner with the Northside Animal Hospital clinic staff.
- I will be respectful of my Veterinarian and care team, and be mindful of the demands they face every day.
Above all, we pledge to spread kindness above hate and to create a more inclusive community.
By checking this box, you agree to the Northside Animal Hospital Kindness Pledge.*

I agree
I understand that I am responsible for payment at the time of services rendered.
Date*

MonthDayYear
Date
Printed Name of Owner or Agent responsible for pet(s):*
By checking this box, you agree and understand that you are responsible for payment at the time of services rendered.*

I agree
Should be Empty:

New Client Questionnaire

First Pet Information

Second Pet Information

Third Pet Information

Northside Animal Hospital Payment Policies

Pet Insurance

Kindness Pledge

I understand that I am responsible for payment at the time of services rendered.