New Client Form
Welcome to the Animal Hospital of Dunedin
*=required
Client Information
Owner Name
*
First Name
Last Name
Spouse or Co-Owner
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Work Number
Please enter a valid phone number.
Cell Number
*
Please enter a valid phone number.
Spouse/Co-Owner Number
Please enter a valid phone number.
Best Email
*
example@example.com
Drivers License #
State
Is your address listed as a PO Box?
Yes
No
Physical Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Pet Information
Pet Name
*
Species
*
Canine
Feline
Guinea Pig
Hedgehog
Ferret
Hamster
Rat
Mice
Gerbil
Turtle
Tortoise
Bearded Dragon
Boa Constrictors/Pythons/Other Non-Venomous Snake
Mini-pig
Breed
*
Color
*
Gender
*
Female
Male
Spayed/Neutered?
*
Yes
No
Birthdate or Approximate Age
*
Microchip (If Applicable)
Current on Vaccinations?
*
Yes
No
History Provided?
*
Yes
No
Not applicable
What hospital can we obtain them from? Hospital Name and Phone Number.
Additional Comments/Concerns
Current treatments, medications. Please list all medications and supplements including name, strength, and directions.
What is the presenting problem/complaint?
How old was your pet when the problem first started?
How has this problem changed?
What diet are you currently feeding your pet? Include treats as well.
Is your pet on flea and heartworm prevention?
Yes
No
Has your pet had any herbal therapy or acupuncture previously?
Yes
No
Are there any other pets in the household?
Yes
No
If yes, what kind? (dog, cat, bird, reptile, other)
Has your pet been diagnosed with any other medical problem?
Is there any additional information that may be helpful?
Have you been referred to us by another hospital? If so which one.
Additional Information
How did you hear about us?
Google
Facebook
Mailer
Walked/Drove By
Internet - Other
Other Hospital
Existing Client
Current Employee
Other
If Internet, where?
Which Hospital?
Who May We Thank?
Which Employee?
If Other, Where?
Photo Consent
We love social media! Do we have your permission to share your pet(s)' image and story on social media, our website, and other forms of related media? Your name and personal information will never be shared. Simply check below to authorize this.
*
Yes. I authorize AHOD to share my pet's story and photo.
No. I do not authorize this.
Treatment Consent
I hereby authorize the veterinarian to examine, prescribe for or treat the above-described pet(s). I assume responsibility for all charges incurred in the care of this animal. I understand that payment is always due IN FULL at the time of service and that a deposit may be required for hospitalization and surgical procedures. I recognize that financial concerns should be discussed PRIOR to exam and treatment. The AHOD staff is happy to provide estimates.I understand that the Animal Hospital of Dunedin does not bill. Acceptable methods of payment are cash, check, Visa, MasterCard, American Express, Discover, and CareCredit. I also understand that if my account is not paid in full that I will be liable for a monthly finance charge of 1.5% and any fees that may be incurred for the services of an outside collection agency.
Signature
*
Today's Date
*
-
Month
-
Day
Year
Date
Submit
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