New Patient Release Form
Please read the following form carefully and double check all entered info for accuracy.
Owner Contact Information
Pet Owner Name (Primary)
First Name
Last Name
Pet Owner Name (Spouse)
First Name
Last Name
Primary Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Secondary Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Pet Owner Mailing Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Pet Information Details
Species of Pet
Please Select
Cat
Dog
Pet Name
Date of Birth
Currently Diagnosed Medical Conditions
I give the attending veterinarian and their staff permission to treat my pet indicated above, and I assume full responsibility for all costs and charges incurred in their treatment.
*
Yes
I understand that payment is due upon services rendered and that payment must be complete before patient leaves the facility, and I agree to these terms.
*
Yes
I give Windsor Animal Hospital permission to release pertinent medical records to requesting entities. This may include, but is not limited to, insurance companies attempting to process claims, other veterinary facilities requesting records, boarding facilities, groomers, etc. I understand this permission can be revoked at any time but must be done so in writing for record keeping purposes.
*
Yes
No
Pet Owner Name
First Name
Last Name
Pet Owner Signature
Date
-
Month
-
Day
Year
Date
Submit
Submit
Should be Empty: