New Patient Forms – North Orange Animal Hospital

Please submit the form below. All information will be used to create your pet's file. Please be as specific as possible. Upon completion this will be emailed to the hospital.

New Client Information

Name*

First Last

Spouse Name

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Email*

Cell Phone*

Home Phone

Work Phone

Pet Information

Pet Name*

First Last

Sex*

Male
Female

Neutered/Spayed?*

Yes
No

Date of Birth or Approximate Age*

Breed

Color

Special Past History/Medications/Allergies

Please be prepared to provide your bank name and driver's license info at your next appointment.

Preferred Method of Payment

Cash
Check
Credit Card

Name of Previous/Current Veterinarian

How Did You Hear of Our Hospital?

I understand every effort will be made to achieve a successful outcome and to provide for all possible safety in hospital care and handling. I hereby authorize this hospital to receive, prescribe for, treat or perform surgery upon the pet(s) listed above and additional pets I present. Furthermore, I agree to pay fees for services rendered at the time the pet is discharged from the hospital or the service is otherwise terminated. I agree to pay for the reasonable costs of collection in the event that collection efforts become necessary. I understand that a service fee of $25.00 will be assessed for each non-sufficient fund check and/or certified letter that must be sent. I understand that veterinary service is provided during nighttime hours as necessary in the judgment of the veterinarian in charge. Continuous presence of qualified personnel may not be provided. If I neglect to pick up my pet within 5 days of the discharge date and do not notify you within that time period, you may assume that my pet is abandoned and are hereby authorized to dispose of my pet as you deem best and/or necessary.*

I Agree

Today's Date*