INFORMATION and FINANCIAL STATEMENT



NEW PATIENT & CLIENT INFORMATION SHEET

Welcome to Pearl River Animal Hospital. So, we may provide you with exceptional service, please share information about you and your pet. Our goal is to provide our clients with the best, compassionate veterinary care.

PATIENT INFORMATION

Pet’s name: ___________________________ Sex: □ Male □ Female Neutered or spayed? □ Yes □ No

Species: □ Dog □ Cat Is your pet microchipped? Yes: _____ No: ____________Do you have pet insurance? _____

Pet’s Date of Birth (Month/Day/Year) _____/_____/_____ Breed__________________________Color_____________________

Reason for bringing pet in: ____________________________________________

Does your pet have any allergies, special medications, or health problems we should know about? □ Yes □ No

If yes, what? _____________________________________________________

What type of food does your pet eat? _____________________________________ Treats? _____________

Do you have other pets? ______________________________________________

Dates of last vaccinations:

Dogs: DA2PP (Distemper/Adenovirus/Parainfluenza/Parvo): ___________ Rabies: _________ Kennel cough: ____ Heartworm test: ___________ Is your dog on heartworm preventives? □ Yes □ No

Cats: FVRCP (Feline Rhinotraceitis/Calicivirus/Panleukopenia): ____________ Rabies: ____________

Where were the most recent vaccinations given? ___________________________________________

Who is your previous veterinarian? ______________________Phone (____) ________________

CLIENT INFORMATION

First name: ____________________________________ Last name: ________________________________________________

Partner first name: _______________________________ Partner last name: __________________________________________

Address: ___________________________________ City: _________________________ State: __________ Zip: ______________

Home phone (______) ______________ Work phone (_____) _______________ Cell (_____) _________________

E-mail address: ________________________________________ Employer _________________________________________

Preferred method of contact? ______________________________

How did you become aware of our hospital? Referral: _________Who can we thank? ___________________

□ Drove by: ______________ Website: : ___________________

Payment is required when services are rendered. For your convenience, we accept cash, MasterCard, Visa, Discover and American Express and Care Credit I verify that all the information provided is accurate, and I am the owner of the pet listed. I hereby authorize The veterinarian to treat the pet described, I also understand that charges will be paid at time of services rendered.

Signed_________________________________________________________________ Date________________________________

Is there another authorized person/agent on your behalf? Please list their name: ______________________________________

[pic] Thank you for allowing us to take care of your pet.

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