New Patient Form

Name: Veterinarian
Brand: All Creatures Veterinary Care Center

Date

Client Information

Name

First

Last

Spouse/Secondary Name (if applicable)

First

Last

Mailing Address

Address

Apt

City/Town

State/Province

ZIP/Postal Code

Home Telephone

Cell Phone

Email Address

Employer’s Name & Address

Patient Information

Name

Species

Breed

Sex

Date of Birth

Are you this pet’s owner?

Yes

Vaccine History:

Please provide pet’s vaccine history and/or copy of prior medical records
One file only.
100 MB limit.
Allowed types: gif, jpg, png, bmp, eps, tif, pict, psd, txt, rtf, html, odf, pdf, doc, docx, ppt, pptx, xls, xlsx, xml, avi, mov, mp3, ogg, wav, bz2, dmg, gz, jar, rar, sit, svg, tar, zip.

If you cannot upload the history above, where we can call to request them?

How did you hear about All Creatures Veterinary Care Center?

Payment Options

All bills must be paid when services are rendered. We do not bill. We accept all major credit cards including Care Credit/Scratchpay. If you have any questions regarding your payment today, please discuss it with a client service representative before seeing the doctor.

Thank you. I assume responsibility for all charges assumed in the care of my pet(s). (Initial Below)

Inital

Authorization Release

I hereby authorize the veterinarian to examine, prescribe for, or treat the above described pet. The doctors and staff at All Creatures Veterinary Care Center are to use all reasonable precautions against injury, escape, or destruction of my animals, but they will not be held liable for any problems that might arise from the care, treatment, or safe-keeping of the animals as it is understood that I, as the owner, assume all the risk.

Signature of Owner

Sign above

Date

Witness

Sign above

Date

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New Patient Form

Payment Options

Authorization Release

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