New Patient Form | Sandy Paws Veterinary Clinic

Name

First

Last

Pet's Name

Pet's Species Pet's Species

Breed

Color

Pet's Age or Date of Birth

Sex

Spayed or Neutered?

Yes

No

Are you the owner / Legal guardian of this pet?

Yes

No

**Please note we cannot treat a pet without owner’s written consent. If you are not the owner, we cannot treat the animal without owner’s permission.

Please provide name of any other Owner or Legal Guardian of this Pet

Are you over the age of 18?

Yes

No

Address

City

State/Province

Zip/Postal

Preferred Contact Phone

Email

Does your pet have pet insurance?

If you have pet insurance, please share with whom you are insured.

Please list the names of other persons (if any) that you authorize us to release your pet to, for pickup, following treatment.

**Please note that we will not release your pet to family members/neighbors,etc. without their names appearing below or by written consent from the pet’s owner

Are there other animals in your household?

Yes

No

Do you give consent to use photos of your pet on social media and make them a star?

Yes

No

If yes, what types of animals and how many?

How did you hear about us?

If someone referred you to us, please list their name here

We have trained staff to restrain your pet for examination or treatment. If you elect to restrain your own pet, please understand we cannot be responsible for any injury incurred to you or your pet.

Yes, I acknowledge and understand

Reason for today’s visit?

Please check all symptoms or problems you’ve recently noticed with your pet

Has your pet ever bitten someone?

Yes

No

Attacked other animal?

Yes

No

Lunged at/attacked people?

Yes

No

Dog Vaccination/Wellness History (If known, please check all vaccinations/tests that your pet has received within the past 12 months)

Cat Vaccination/Wellness History (If known, please check all vaccinations/tests that your pet has received within the past 12 months)

Is your pet on heartworm prevention?

Yes

No

Is your pet on flea prevention?

Yes

No

What is your pet’s medical history (such as surgeries, ongoing medical issues, allergies, seizures, etc.)

Names of other veterinarians who have treated your pet?

Please confirm you read and understood all the above by signing your full name below.

NOTE THAT PAYMENT IS DUE AT TIME SERVICES ARE RENDERED. NO BILLING OR INVOICES.

We accept the following forms of payment: Cash | Credit | Card | Scratch Pay

Note: To help prevent and deter identity theft, we will require a current driver’s license or United States passport - to verify personal information and funds, if applicable. Thank You!

I understand that FULL PAYMENT OF ALL FEES ARE DUE AT THE TIME SERVICES ARE RENDERED TO MY PET and I shall take full responsibility for payment of all charges related to the care of my pet prior to leaving the clinic or when services have been completed. I acknowledge and accept that, should payments not be honored by my bank, credit card organization or by pet insurance organization to Sandy Paws Veterinary Clinic – for any reason – then I shall pay the full amount within five (5) days of demand – including all applicable costs incurred by Sandy Paws Veterinary Clinic (and its agents) for collection of those funds.

As indicated by my signature, I have read and acknowledged all information provided to me on this Registration Form (on these two pages) and verify the information I have provided is correct.

Signature

Clear