First Appointment

Appointment Date *

Appointment Time *

Owner Information

Owner First Name *

Owner Last Name *

Address *

City *

State *

Zip Code *

Primary Phone *

Email *

Mobile Phone

Work Phone

Employer

Employer Address

Spouse/Other Information

Spouse/Other Name

Children (first name and ages)

Spouse/Other Phone

Spouse/Other Employer

Spouse/Other Employer Address

Spouse/Other Work Phone

Spouse/Other Mobile Phone

Emergency Contact

Primary Emergency Contact Name *

Primary Emergency Contact Phone *

Do you authorize your emergency contact(s) to make urgent treatment decisions if you are unreachable? *

Yes

No

Do you authorize your emergency contact(s) to receive patient information in addition to your primary care veterinarians? *

Yes

No

How did you first hear of our Hospital?

Select one of the following *

Individual

Internet

Yellow Pages

Hospital Sign

Primary Care Veterinarian

Humane Society

Other

If an individual or other, whom may we thank for the referral?

Patient Information

Pet Name *

Birth Date / Age *

Species *

Breed / Other Species *

Color

Vaccination Status *

Gender *

Spayed or Neutered? *

Presenting problem, special needs, concerns *

Primary Veterinarian Information

Please fill this section in if we are not your primary care veterinary hospital. By listing your primary care veterinarian, you are authorizing Cinder Rock Veterinary Clinic to release patient information to the primary care hospital or veterinarian.

Primary Care Facility

Primary Care Veterinarian(s)

By submitting this form, I hereby authorize Cinder Rock Veterinary Clinic to render medical care for my pet(s) as deemed necessary by the veterinarian. I understand that no guarantee can be given to the outcome of treatments and take it as my responsibility to comprehend any risks involved. I agree to pay for the cost of all services to which I consent to by written or verbal estimate. I understand that a deposit is required before diagnostics and treatments can be initiated and that payment in full is required prior to discharge of patient from Cinder Rock Veterinary Clinic.

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New Client Form

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