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New Client / Patient Form
Owner Information
(You) - Please review all fields and fill them as needed
Client Full Name
*
Address
*
Home Address
Street Address Line 2
City/State/Zip
State / Province
Postal / Zip Code
Apartment number (If needed)
Cell Phone Number
*
Email Address
example@example.com
Client Employer
Work Phone
Alternate/Emergency person to contact if needed (Full Name)
Emergency/Alternate Person Phone Number
If children live in the household please list names and ages
How did you hear about us
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Co-Owner Information
By listing this person as Co-Owner for your pet you give them permission to make medical and financial decisions unless removed from your account. (Skip if your pet does not have a co-owner)
Co-Client Full Name
Co-Client Cell Phone
Co-Client Email
example@example.com
Co-Client Employer
Co-Client Work Phone
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Patient Information
(Your Pet)
Patient Name
*
Species
*
Please Select
Dog
Cat
Breed
Color(s)
*
Date of Birth or AGE
Sex
Please Select
Male
Female
Is your pet Spayed/Neutered?
Please Select
YES
NO
Unsure
Date of Spay/Neuter
/
Month
/
Day
Year
Date (If known)
How long have you owned this pet?
What brand of food do you offer your pet?
Is your pet on Heartworm prevention?
Please Select
Yes
No
List product name
Date last given
/
Month
/
Day
Year
Date
Is your pet on Flea prevention?
Please Select
Yes
No
List product name
Date last given
/
Month
/
Day
Year
Date
Previous Animal Hospital(s)
Can we call this facility for records?
Please Select
Yes
No
**Be mindful some facilities such as, but not limited too ex. Kaaws & Banfield etc., will require an owner to call/relase records to us.
Please list any vaccine reactions, drug allergies, medical problems, current medications, or behavioral problems
Does your pet have a Microchip?
Please Select
Yes
No
Unsure
Microchip Number
Upload Previous Records for your pet's medical history (If any)
Browse Files
Drag and drop files here
Choose a file
If you have psychical copies please bring them to your appointment
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of
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Payment Information
Payment is due when services are rendered. In some cases a deposit may be required in advance. You may pay by cash, personal check (with proper identification), CareCredit, Visa, Master Card, American Express, or Discover. There will be a $25.00 service charge on all returned checks. >> In order to avoid misunderstanding, we urge that all fees be discussed before services are performed.
Signature of Responsible Party YOU
*
Today's Date
*
/
Month
/
Day
Year
Date
Please review and approve or decline:
I would like to receive my pet's health care reminders & have Newsletters sent to my email address listed above
*
Approve
Decline
Please Date and Initial to decline
I agree and grant Easton Commons Animal Hospital permission to take photographs/videos of me and/or my pet and to copyright, use and publish the same in print and/or electronically, with or without my name/pets name and for any lawful purpose, including, for example, such purposes as publicity, illustration, advertising and Web content
*
Approve
Decline
Please Date and Initial to decline
Do you currently have an appointment scheduled at our facility?
*
Yes
No
What is the date of your scheduled appointment?
-
Month
-
Day
Year
Date
Please call to schedule an appointment at 281-550-6960
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