New Patient Form Client InformationName:(Required)Co Owner Name:Mobile Phone #:(Required)Co Owner Mobile Phone #:Work Phone #:Work Phone #:Address:(Required) Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Prior Vet Clinic NamePrior Vet Clinic Phone #:How Did You Hear About Us? Website Facebook Drove By Other/Personal Referral Whom we may thank?Referring Veterinarian InformationPractice NamePractice PhoneVeterinarian NamePet InformationPlease select the number of pets first whom you want to enroll.Please Select the number of pets(Required) One Two Three Four If you have more then four pets we can add the rest at a later time!First PetFirst Pet Name(Required)First Pet SpecieFirst Pet BreedFirst Pet ColorFirst Pet Date of Birth / Estimated AgeFirst Pet Heartworm PreventionFirst Pet Allergies to Vaccines / MedicationsFirst Pet Sex(Required) Male Female Neutered? Spayed? First Pet Previous Surgery / IllnessFirst Pet Special Diet / Medications / SupplementsNotes for First PetAuthorization & Digital Communication Consent(Required)I authorize the hospital to release my pet’s medical information to other veterinary hospitals, groomers, and kennels, including my phone number if my lost pet is recovered. I acknowledge that conversations during my pet’s visit may be recorded for quality assurance and service improvement purposes. I hereby grant the hospital all rights, title, and interest in any photographs, images, videos, or audio recordings of my pet or myself taken during my pet’s visit. This includes the use of such materials for promotional purposes, on the hospital’s website, and other marketing materials. If the veterinary team determines that immediate treatment is necessary for the health and well-being of my pet, and I or my co-owner are unable to be reached, I consent to the administration of all reasonable treatments recommended. I assume responsibility for all charges incurred for my pet(s) and understand that payment is due at the time services are rendered. I understand that the hospital offers various forms of digital communication to keep me informed about my pet’s health, remind me of upcoming appointments, and share promotions and health tips. By signing below, I authorize the hospital to contact me via email, phone, and/or text message (SMS). I understand that I can opt out of these communications at any time by following the unsubscribe instructions in any communication received. I confirm that I am 18 years of age or older and legally authorized to consent to veterinary treatment and assume financial responsibility for all services rendered. I had read and agree to the above Terms & Conditions.Signature of Owner/Agent(Required)Date(Required) MM slash DD slash YYYY Second PetSecond Pet NameSecond Pet SpecieSecond Pet BreedSecond Pet ColorSecond Pet Date of Birth / Estimated AgeSecond Pet Heartworm PreventionSecond Pet Allergies to Vaccines / MedicationsSecond Pet Sex Male Female Neutered? Spayed? Second Pet Previous Surgery / IllnessSecond Pet Special Diet / Medications / SupplementsNotes for Second PetThird PetThird Pet NameThird Pet SpecieThird Pet BreedThird Pet ColorThird Pet Date of Birth / Estimated AgeThird Pet Heartworm PreventionThird Pet Allergies to Vaccines / MedicationsThird Pet Sex Male Female Neutered Spayed Third Pet Previous Surgery / IllnessThird Pet Special Diet / Medications / SupplementsNotes for Third PetFourth PetFourth Pet NameFourth Pet SpecieFourth Pet BreedFourth Pet ColorFourth Pet Date of Birth / Estimated AgeFourth Pet Heartworm PreventionFourth Pet Allergies to Vaccines / MedicationsThird Pet Sex Male Female Neutered Spayed Fourth Pet Previous Surgery / Illness:Fourth Pet Special Diet / Medications / Supplements:Notes for Fourth Pet