New Patient Release Form

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 NameLast Name
Pet Owner Name (Secondary)

First NameLast Name
Do you already have an account with us?
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

CityState / Province

Postal / Zip Code
Pet Information Details
Species of Pet
Sex
Pet Name
Date of Birth
Pet Breed
Pet Color
Currently Diagnosed Medical Conditions & Current Medications (both prescription and non-prescription):
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.
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.
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.
Pet Owner Name

First NameLast Name
Pet Owner Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
You may upload any records from breeders, rescues, previous veterinarians, etc. that may be pertinent to your pet's care with us. These files can be PDF scans or even clear photos of records taken with your phone.

Cancelof
ATTENTION: If you do not have an appointment for this pet, or if you need to finalize the above account, please contact our office. If we do not hear from you, the above information will be added to our system and we will wait for your call. We will not contact you to make an appointment. Thank you!
Should be Empty:

New Patient Release Form

Owner Contact Information

Pet Information Details