Northeast Animal Clinic - New Patient Form

1
First Name
Last Name
Address
City
State
Zip Code
Home Phone
Cell Phone
2
Email Address
Driver's License #
Social Security #
Date of Birth
3
62 years of age-or older?
Yes
No
4
Active or retired member of the United States Military?
Yes
No
5
Do we have permission to post pictures of your pet on social media?
Yes
No
6
Emergency Contact (optional)
Name
Phone #
Name
Phone #
7
Payment TypePAYMENT IS DUE IN FULL AT THE TIME THE SERVICES ARE RENDERED
Check
Cash
Credit/Debit
8
I understand that if I do not pay this account as agreed, that past due accounts are subject to collections costs, including interest and attorney fees. I understand that the clinic staff will provide an estimate of current and anticipated charges any time I request one.

I am requesting that veterinary care be provided for the pets presented by me or my
agents. I understand that I am financially responsible for all services rendered.

NO CALL NO SHOW POLICY
24 hour notice is required for all cancellations, or rescheduled appointments. Failure to
communicate with us will result in a $62 no show fee.

I accept the $62 no show fee, if I do not show up for my appointment. *
9
Signature* This field is required.
Clear
10
Date* This field is required.
Date
Year
Month
Day
11
Pet's Name
Canine
Canine
Feline
Canine / Feline
Breed
Color
Date of birth or Approximate Age
Female
Spayed Female
Male
Neutered Male
Sex
12
Previous Veterinarian/Clinic
Date of Last Exam
Yes
No
Is your pet on heartworm prevention?
Brand
Yes
No
Is your pet on flea & tick prevention?
Brand
Microchip #
Yes
No
Does your pet have any major medical conditions?
13
Please Explain
14
Name
Canine
Canine
Feline
Canine / Feline
Breed
Color
Date of birth or Approximate Age
Female
Spayed Female
Male
Neutered Male
Sex
15
Previous Veterinarian/Clinic
Date of Last Exam
Yes
No
Is your pet on heartworm prevention?
Brand
Yes
No
Is your pet on flea & tick prevention?
Brand
Microchip #
Yes
No
Does your pet have any major medical conditions?
16
Please Explain
Should be Empty:

NO CALL NO SHOW POLICY