New Client and Patient Information Form New Client and Patient Information Form Are you a new client? * Yes No Are you a current client with a new pet? * Yes No Do you have information that needs to be changed? * Yes No Owner Information Name of authorized owner * Name of authorized owner First First Last Last Spouse Spouse First First Last Last Address * Address Address Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Home Phone Cell Phone Email * Your date of birth * (This is required by the DEA.) How did you find us (please check all that apply)? * Our Website Google, Yahoo, etc. YP.com (online Yellow Pages) Twitter Facebook Phone Book (Yellow Pages, etc.) Newcomer's Welcome Service Community Event Driving by the hospital My friend referred me and their name is:My friend referred me and their name is: Saw an ad in (please indicate where):Saw an ad in (please indicate where): Pet Information New Patient Name * Species * Dog Cat OtherOther Breed * Color * e.g. brown, black and white, etc. Date of birth (If you don't know, give your best guess) Age (If you don't know, give your best guess) Sex * Male Female Spayed/Neutered? * Yes No Unsure plus1 Add Pet minus1 Remove Pet Veterinary Records If you consent to your previous Veterinarian releasing their medical records for your pet(s) to the Ann Arbor Animal Hospital, then please provide your previous Veterinarian’s contact information below. We request this so that we can have the medical records (e.g., vaccine history, Heart Worm testing, etc.) for your pet(s) sent directly to us. Having this helps us provide better care to your pet(s). Veterinarian Name Veterinarian Phone Number Would you like us to release the medical records for your pet(s) to ALL veterinary offices, boarding facilities, groomers, etc. that request that information from us? * Yes No If you would like us to release medical records only to specific entities, then please list any individuals, veterinary clinics, boarding kennels, pet insurance providers, etc. to whom you would like us to release the medical records for your pet(s): Anyone else authorized to order treatment: Name Phone Optional Photo Release Authorization* I give permission for Ann Arbor Animal Hospital to use my pet's name, photograph, or medical information for blog and social media purposes. *Consent for photo release is NOT necessary to obtain services Authorization for Treatment I authorize the release of my pet’s medical records as specified above and will assume responsibility for all fees incurred: Owner's signature * signature keyboard Clear Today's date * Note: All professional fees are due at the time services are rendered. Monies owed for services not paid at the time services are rendered are subject to billing fees and interest. Captcha Submit If you are human, leave this field blank.
