New Patient Form

Please note: this form is for demonstration purposes only, no pet care is available from this site.

Marked Fields Are Required [*]

Owners Name:

First Last

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

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.

Signature

Date

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Comments

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