New Patient Form | Como Park Animal Hospital

New Client Information

Thank you for choosing us for your pet’s healthcare. We are very excited to meet you and your pet. Please be sure to pre-register your pet’s information online, and get us the medical information we need to make your pet’s first appointment a success. Please arrive 10 minutes before your scheduled appointment to help keep your appointment with the Doctor on time. This form is not for our urgent care, AfterHours cases. If this is an emergency, please visit us at www.afterhoursveterinarycare.com/ The signer of this document and primary owner listed must be 18 years or older. Please include any co-owners. Minors and those not listed will not be allowed to make medical decisions. Information will not be shared with outside parties without your consent. *You must call to make an appointment.

Owner's Name(s)*
First Last
Email*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Phone*
Cell Phone
Work Phone
Can we reach you by text?*
Were you referred to us?*
Who referred you to us?
Name of Patient*
First
Patient Sex*
Species*
Breed*
Age / Date of Birth*
Color(s) / Markings*
Do you have other pets in the house?*
Please list the species of your other pets.*
Please list other past or current Veterinary providers.*
What is the reason for this visit?*
Authorization and consent for services*
I agree.
I verify that all information contained in this document is correct and current. I will notify Como Park Animal Hospital of any changes to my contact or ownership information. I authorize that I am the owner of this patient, that I am at least 18 years of age and that I have the authority to authorize medical care for this pet - surgery, diagnostics, treatments, and euthanasia – to be performed by Como Park Animal Hospital, or AfterHours Veterinary Care on their behalf.
Medical Records Release*
I agree.
I give consent to release medical records for this patient. We will still ask for verbal authorization and a reason for transfer of records. This is for protection of your privacy and security of legal medical information.
Payment for all services are due at time of services performed.*
I agree.
I understand that I am financially responsible for all services rendered. A deposit may be required for certain medical or surgical procedures. The hospital accepts payment by Cash, Tele-Check, Visa, MasterCard, Discover, American Express, CareCredit, and Scratchpay. A $35.00 service fee will be applied to all returned checks. Balances over thirty days will be subject to interest at the rate of 1.5% per month. I understand that if the balance is not paid in a timely fashion, I will be responsible not only for the balance due, but any collection agency fees, court costs, and/or attorney fees that are incurred in the attempt to collect this debt.
Legal Responsibility*
I agree.
By signing below I assume full legal and financial responsibility for the above listed pet.
Electronic Signature*
I agree to the privacy policy.
By selecting the "Submit" button, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual signature on this form.