New Patient Form

Marked Fields Are Required [*]

Owners Name:
First Last
Email
Address
Street Address Address Line 2 City State ZIP Code
Home Phone:
Cell Phone
Work Phone
Employer
Address
Business Phone
Would you like to add an additional owner(s) to the account?
- YES
- NO
Additional Owners
Full Name Phone# Relationship
PAYMENT IN FULL IS EXPECTED AT TIME OF SERVICE
Please indicate your preferred form of payment:
- Cash
- Check
- Credit Card
How did you learn about our hospital?
Number of household dogs
Number of household cats
I grant Demo Veterinary Website representatives and employees the right to take photographs of me and/or my pet, and to copyright, use and publish the same in print and/or electronically, with or without my name and for any lawful purpose, including, for example, such purposes as publicity, illustration, advertising and Web content.
- The above may take photos of me and/or my pet
- The above may NOT take photos of me and/or my pet
Professional fees are to be paid at the time services are rendered. There will be a $25.00 fee on all returned checks. Please read carefully. Signature is required before exam or treatment. I hereby consent and authorize Demo Veterinary Website, Inc., its doctors and representatives to administer such treatment, diagnostic, surgical, and anesthetic procedures as they deem necessary. None of the above will be held liable or responsible in any manner whatsoever, under any circumstances, for the care, treatment or safekeeping of animals, as it is understood, I assume all risks. I hereby certify that I have read and fully understand the above authorization for medical and/or surgical treatment. I also agree that no guarantee or assurance has been made as to the results that may be obtained. Furthermore, I assume financial responsibility for all charges incurred to patient, consent to release of medical information, and authorize direct payment to Demo Veterinary Website. This practice’s financial policy is that payment is due at the time services rendered.
Consent
I understand that I am financially responsible for payment of all bills for veterinary services, late charges, and collection costs.
Signature
Date
Month
Day
Year
CAPTCHA

Full Name	Phone#	Relationship

New Patient Form

PAYMENT IN FULL IS EXPECTED AT TIME OF SERVICE