New Patient Form

Thank you for visiting our hospital. We look forward to getting to know you and your pet. Please help us to provide the best care possible for your pet by taking a moment to fill out this form.

Client / Owner Information

First Name

Last Name

Address

Address Cont'd

City

State

ZIP

Home Phone

Cell Phone

Work Phone

Email *

Do you prefer phone, email, mail or no preference for correspondence?

Spouse / Co-Owner Information

First Name

Last Name

Cell Phone

Work Phone

How did you hear about us?

Other

Doctor Referral

If you have been referred to us by another veterinarian, please provide their information below.

Doctor's Name

Hospital Name

State

Phone

Please tell us about your pet(s)

Name

Type of Pet

Other

Breed

Color

Date of Birth or Age if Unknown

Sex

Vaccination Dates

Please list all vaccination dates, if known, for the following:

Rabies

Spayed / Neutered?

Distemper/Parvo or FVRCP

Leptosporosis (Dogs)

FeLV (Cats)

FeLV/FIV Test (Cats)

Result

Fecal Test

Heartworm Test

Microchipped? (Date)

What do you feed your pet?

Does your pet have any previous medical conditions?

Please List your pet's current medication(s)

Has your pet had any surgeries (besides spay/neuter) or dentistries (specify and dates)

Does your pet have any allergies to vaccinations, medications, food, fleas, etc?

Does your pet have any "favorites" (i.e. loves chin scratches, peanut butter etc)?

Please tell us about your pet(s)

Name

Type of Pet

Other

Breed

Color

Date of Birth

Month

Day

Year

Sex

Spayed / Neutered?

Do you have Pet Health Insurance?

Insurance Provider

I authorize the staff of Metropolitan Veterinary Center to use photographs of this pet for promotional purposes including but not limited to brochures, their website and social media sites such as Yelp, Facebook, Instagram, or Google. (please initial_ *

I certify that I am the legal owner or authorized agent of the animal listed above. I am at least (18) years of age and I assume total financial responsibility for the costs of services rendered by Metropolitan Veterinary Center as well as responsibility for the decisions regarding care and treatment of the animal(s) described herein. I understand that full payment is required at the time services are provided. I understand that upon my request the hospital staff will provide an estimate of any current and / or anticipated charges. By signing below, I am authorizing veterinary care be provided for the above described pet, presented by me or by my directed agent(s) to Metropolitan Veterinary Center. I understand that veterinary care may include, but is not limited to, examination, prescription or administration of medication or medical treatment including surgery.

And to the best of my knowledge, the above information is accurate.

Please sign your name below using your mouse as a cursor:

Signer Name *

New Patient Form

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