New Client/Patient Information Form

Thank you for choosing Emerald Hills Animal Hospital! We are pleased to welcome you and your family to our practice. Please take a few minutes to fully complete this form so we may better serve you. We look forward to a long and rewarding relationship with you and your pet(s).

New Client Information

Owner's Name:

Spouse/Other:

Street Address:

City, State and Zip:

Primary Phone Number:

Spouse/Other Phone Number:

Email Address:

How did you hear about us?

Previous Veterinarian:

Phone Number:

Name of Employer:

We will gladly prepare a written estimate if you desire. This will be important since ALL PROFESSIONAL FEES ARE DUE AT THE TIME SERVICES ARE RENDERED. In cases of extensive medical or surgical procedures when full payment may be difficult at discharge we also take MasterCard, Visa, Discover and American Express. There will be a $25.00 service charge for any check returned unpaid.

Pet #1 - Patient Information

Name:

Breed:

Date of Birth / Approximate Age:

Color:

Sex:
FemaleFemale SpayedMaleMale Neutered

Microchip:
YesNo

Any Pet Insurance:
YesNo

Pet #2 - Patient Information

Name:

Breed:

Date of Birth / Approximate Age:

Color:

Sex:
FemaleFemale SpayedMaleMale Neutered

Microchip:
YesNo

Any Pet Insurance:
YesNo

Pet #3 - Patient Information

Name:

Breed:

Date of Birth / Approximate Age:

Color:

Sex:
FemaleFemale SpayedMaleMale Neutered

Microchip:
YesNo

Any Pet Insurance:
YesNo