New Client Information

Client Information
Welcome to Pearl Animal Hospital! We look forward to meeting you and your pet(s). Please fill out the following form and we will be in touch with you within 48-72 hours to schedule your initial visit.

Please use this link to complete the following form for each additional pet:

NEW PATIENT LINK

Please be advised that we require a refundable deposit equal to the cost of the initial examination ($92) at the time of scheduling.

If you are no longer able to make your appointment please let us know as soon as possible and we will refund that deposit. However, if you cancel within 24 hours or do not show up to your scheduled visit, the deposit will be forfeited and you will be asked to place another deposit if you choose to reschedule.

Thank you and we cannot wait to meet you!
Owner Name*

First NameLast Name
Owner Pronouns*
Phone Number*

Area CodePhone Number
Co-Owner Name

First NameLast Name
Co-Owner Pronouns
Phone Number

Area CodePhone Number
Address*

Street Address

Street Address Line 2 (Apt/Unit#)

CityState

Postal / Zip Code
Email*
example@example.com
Secondary Email
example@example.com
Occupation*
How Did You Hear About Us?*

GoogleLives NearbyFriend ReferralNew AdoptionInstagramFacebookPost CardYelpOther
If you chose Friend Referral, who referred you? *
First and Last Name
If New Adoption, where did you adopt from and when?*
Patient Information
Pet Name*
Species:*

CanineFeline
Breed: *
Color*
Sex:*

FemaleMale
Spayed or Neutered:*

YesNo
Microchipped?*

YesNo
Birthdate

MonthDayYear
Date
Age*
Pet Insurance Company*
Pet Insurance Company/Policy Number
If you chose other, please let us know which company in this line. Include policy number
For insurance submission, many companies make it easy for you to submit insurance through an app or on your own.

We are happy to submit insurance and medical records on your behalf if your insurance company will allow. Please provide a blank, signed and not dated form at your first visit.

We will always send you copies of your invoices.
Do you want PAH to submit insurance for you?*

No, I prefer to submit insurance myselfYes, please submit and I will provide a blank, signed, and not dated form to keep on fileI do not have pet insurance.
If you have a blank, signed (not dated) form, please upload here to keep on file.

Browse Files

Cancelof
To help us best prepare for your visit, please provide a detailed list of the previous veterinary clinics your pet has visited so that we may request records.

A full medical history allows us to make the most appropriate recommendations based on your pet's individual needs. This includes proper vaccination recommendations and lab testing.

Please include the name, state, and phone number (if available) of every veterinary clinic (include ER, urgent care, and specialty hospitals) your pet has visited.

Please include all adoption records you have since it can be very diffcult to obtain records from adoption facilities.
Previous Veterinary Hospitals your dog/cat has been seen (Include adoption/rescue agency if applicable): *
Please provide name of Veterinary Clinic or Rescue, city, and state if outside Portland
Please upload any medical history and adoption records you may have for your pet.

Browse Files
We will also call previous veterinary hospitals for full medical records. Cancelof
Where did you get your pet and how long have you had them? *
What states/countries has your pet traveled to? *
Do you have any other pets or children in the household? *
Please be specific.
Any pertinent medical history? *
Any chronic illnesses or diseases we need to know about?
Has your pet had surgery or an anesthetic procedure before? *
Please be specific and list all known procedures, with dates if known
Has your pet been anxious or fearful for veterinary visits in the past? *
Has a veterinarian ever recommended or prescribed an anxiolytic (anti-anxiety medication) for your pet in the past?*

YesNo
If you chose yes above, please tell us about the medication (trazodone/gabapentin/etc.) and how your pet did with the medication. *
To help facilitate a comfortable examination, we can provide a Fear Free dose of an anxiolytic prior to your pet's visit. We want to be able to provide the least stressful and best possible experience for you and your pet. Would you like us to prepare a Fear Free Dose ($5-$10) for your pet's initial visit?*

YesNoI'm unsure, please discuss with me more.
Are there any specific issues you would like addressed at your initial visit? Do you have a specific goal for your initial visit?*
Please share a picture of your pet for their medical record. *

Browse Files
This photo is for internal use only and will not be shared to social media. Cancelof
Do we have permission to use photographs/video of your pet on our website, Facebook, or Instagram?*

YesNo
Fee Policy
All professional and medical services must be paid in full at the time services are rendered.

We accept Cash, Visa, Mastercard, American Express, Discover, Debit Cards, and Care Credit. We do not accept personal checks.

As a pet guardian, you will be held liable for the financial responsibility of services that are performed for each pet. Payment is due, in full, at time of service. Unpaid balances will be recovered as deemed appropriate by Pearl Animal Hospital management.
Please initial that you agree and understand our fee policy. *

Clear
Cancelling and Rescheduling
All new patients require a deposit equal to the current exam fee at the time of scheduling.

If you need to cancel or reschedule your appointment, please notify us with a minimum of 24 business hours to refund your deposit.

If you need to cancel or reschedule your appointment within 24 hours of the appointment time, the deposit will be forfeited.
Please Initial that you understand and agree to the cancellation/rescheduling policy*

Clear
Multnomah County Requires all veterinarians administering rabies vaccinations to report client and pet information, including address, telephone number, breed information, and the date the rabies vaccine was given, to Multnomah County Animal Services.

*Please note that all phone calls are recorded for quality assurance.

We are required to provide medical records when requested by attending veterinarians and those listed on this form unless otherwise indicated.
I have read and abide by the above statements:*

Clear
Today's Date*

MonthDayYear
Date
Should be Empty:

Client Information

Patient Information

Fee Policy

Cancelling and Rescheduling