Hurricane Animal Hospital New Patient Information Form and Welcome

Hurricane Animal Hospital New Patient Information Form and Welcome
New Patient Information Form and Welcome

Thank you for giving us the opportunity to care for your pet. We will be happy to answer any questions you may have about our services or your pet’s health. To ensure the best possible care, please take the time to read and complete this form.
Owner or Agent’s Name:

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone:

Area CodePhone Number
Cell/Mobile Phone:

Area CodePhone Number
Work Phone:

Area CodePhone Number
Other:

Area CodePhone Number
It is Best to contact me (9am-5p) on the

HomeCellWorkOther Phone
We utilize services for confirming appointments via text messaging or email. Which is best for you?
Text to
email at
Name of the pet visiting today
Species

DogCatRabbitOther
Breed, if known:
Color:
Birthdate or Age:
Sex:
Spayed/Neutered?

YesNo
Has your pet ever bitten or tried to bite or scratch someone caring for it?

YesNo
Does your pet have allergies?

YesNo
If so, please list:
Has your pet ever had a reaction to a vaccine or medication?

YesNo
If yes, please list details:
Reason for today’s visit:
How did you hear about us?

WebsiteFacebookVet referral (if so who can we thank?)Family/Friend member (if so, who can we thank?)Business Sign (drive by)Newspaper adPreviously client with another petHumane Society or ShelterOther
Tell us about yourself to help us save you money on your pet care:
Are you a military veteran or active military? (Please provide card at reception desk)
Are you a senior citizen (over age 55)? (Remember to notify us when you turn 55!)

YesNo
Do you have pet insurance for this pet?

YesNo
I am interested in getting information today on securing pet insurance
Hurricane Animal Hospital tries to maintain a low stress environment for our patients. We ask that you keep your pets secure on a leash or in a carrier so we can reduce stress to other patients. We provide a cat ONLY waiting area and exam room and ask that you utilize these areas with your cat to help reduce their stress from dogs they do not know. We also provide relaxing pheromones that our customer care team can help you apply while you wait in our waiting area or in the exam rooms. With your help and guidance, we can use many tools, from treats to low dose sedation or anxiety medications, to make your pet’s visit more comfortable for everyone from home to the hospital and back home.

For your convenience, at the time we perform services, we accept Mastercard, Visa, American Express, Care Credit, as well as check (with a valid driver’s license) or Cash payment. Hurricane Animal Hospital does not require personal information as a condition to payment by credit card, but card users may be required to provide proof of identity.

I hereby authorize the veterinarian to examine, prescribe for, and/or treat the previously described pet. I assume responsibility for all fees incurred in the care of this animal. I also understand that these charges are to be paid at the time of service and that a deposit will be required for any procedure that requires hospitalization, surgery, or after hours care. It is my obligation to ask for a written estimate for the services discussed prior to the care being provided, if I do not request an estimate I understand I am still responsible for the cost of all services provided.
Signature of Responsible Party:

Clear
Date

MonthDayYear
Date
Signature of Spouse when listed:

Clear
Date

MonthDayYear
Date
I understand Hurricane Animal Hospital takes photos of procedures and patients at various times for use in advertising materials, training & education, Facebook, story boards, and their website.

I am consenting that photos of my pet may be used in advertising without me being notified in advance or financially compensated.
Signature

Clear
I would like photos of my pet to NOT be used in marketing and advertising, training, or other media forms.
Signature

Clear
Should be Empty: