New Patient Form - Binder Animal Hospital

Client and Contact

First and Last Name

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Home Phone*

Cell Phone*

Email*

How did you become aware of this clinic?

Choose one*

If other, please specify

Emergency Contact Person*

Home Phone*

Cell Phone*

Name of Previous Veterinarian

Phone of Previous Veterinarian

Pet Information

Pet 1

Pet 1 Name*

Sex*

Species*

Breed*

Color*

DOB*

Pet 2 (optional)

Pet 2 Name

Sex

Species

Breed

Color

DOB

Pet 3 (optional)

Pet 3 Name

Sex

Species

Breed

Color

DOB

May we release records if necessary? (i.e. groomer, boarding kennel, classes, other veterinarian)*

Yes
No

Method of Payment*

Consent*

I hereby authorize the veterinarian to examine, prescribe for or treat the above described pet(s). I understand that all animals must be current on vaccinations and testing for boarding, grooming, daycare and hospital procedures. I assume all responsibility for all charges incurred in the care of my animals. I also understand that these charges will be paid for at the time of release and that a deposit may be required for surgical treatments or hospitalization.

Photo Release: I agree that Binder Animal Hospital may use such photographs of me and/or my pet(s) with or without my name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising, web content, or social media sites. I have read the above statement and by submitting this form, I understand and agree to the conditions above.*

Accept