New Patient Information

Thank you for entrusting us with another family member! So that we may be better able to meet your needs, please complete the following. If you would prefer to download a PDF of this form and fill it out by hand, please click here to do so.

Pet's Name:
Species:	Canine Feline Other
If Other, Please Specify:
Breed:
Color:
Date of Birth:	mm/dd/yy
Your Pet's Gender:	Male Female
Is your pet Spayed or Neutered?	Yes No
Microchip:
Tattoo:
Serious Health Problems (If Any):
Drug Allergies:
Date of Last Exam	mm/dd/yy

AUTHORIZATION FOR EXAMINATION, TREATMENT AND ASSUMPTION OF FINANCIAL RESPONSIBILITY I, the undersigned, authorize the veterinarian (s) and their staff to examine the patient described above and to administer any medical, surgical treatments and / or tests, including sedation or anesthesia which is considered necessary based on findings during the course of examinations. I assume responsibility for all charges incurred for services rendered to the patient. I understand there is a $30.00 service charge for returned checks. I also understand that these charges will be paid at the time of release and that a deposit may be required for hospitalization and / or surgery.

	I Agree
Signed, (Your Name)
Your Email Address