New Patient Registration FormNew Client Form Name First Last Spouse/Co-Owner First Last Address Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home PhoneWork PhonePrimary Cell NumberCo-Owner's CellCo-Owner's WorkEmail Emergency ContactEmergency Contact PhoneAre you or the co-owner an active or retired member of the military?YesNoHow did you become aware of our clinic? Drove by/Sign Facebook Web Page Newspaper Ad OtherOtherPersonal Recommendation (Who may we thank?)Best method to reach you:Home PhoneCell PhoneHow would you like your reminders set?E-MailPostal MailNoneWhat clinic have you previously taken your pet(s) to?Do you have pet insurance? If so, by whom is your pet covered?Do we have your permission to use your pets’ picture in promotional materials such as Facebook and/or our web page?YesNoPet's NamePet 1Species (Dog, Cat, etc.)BreedCoat ColorSexMaleFemaleSpayed/Neutered?SpayedNeuteredNeitherDOB/AgeHow many hours per day does your pet spend outdoors?Date of Previous Vaccinations Date Format: MM slash DD slash YYYY Is your pet microchipped?YesNoBrand of FoodNames of current medications (including flea/tick and heartworm prevention)?Any previous illnesses or surgeries?Pet's NamePet 2Species (Dog, Cat, etc.)BreedCoat ColorSexMaleFemaleSpayed/Neutered?SpayedNeuteredNeitherDOB/AgeHow many hours per day does your pet spend outdoors?Date of Previous Vaccinations Date Format: MM slash DD slash YYYY Is your pet microchipped?YesNoBrand of FoodNames of current medications (including flea/tick and heartworm prevention)?Any previous illnesses or surgeries?Pet's NamePet 3Species (Dog, Cat, etc.)BreedCoat ColorSexMaleFemaleSpayed/Neutered?SpayedNeuteredNeitherDOB/AgeHow many hours per day does your pet spend outdoors?Date of Previous Vaccinations Date Format: MM slash DD slash YYYY Is your pet microchipped?YesNoBrand of FoodNames of current medications (including flea/tick and heartworm prevention)?Any previous illnesses or surgeries?If you have more than three pets, let us know!Is there anything else we should know about your pet?I understand that my veterinarian will need to communicate with me, or someone designated by me, prior to treatment of my animal(s) in order to obtain informed consent. For purposes of obtaining informed consent, I direct my veterinarian as follows:Informed consent may ONLY be provided by me:YesNoInformed consent may be provided by me OR the co-owner(s) above:YesNoInformed consent may also be provided by:Financial PolicyIn order to maintain high quality veterinary care while keeping our cost under control, ALL PROFESSIONAL FEES ARE DUE AT THE TIME SERVICES ARE RENDERED.I authorize Prairie View Animal Hospital to acquire any medical or surgical records from my previous veterinarian and/or send copies of any medical or surgical records to any veterinarian, pet grooming shop, or kennel.Signature (Name)Date Date Format: MM slash DD slash YYYY
