Clocktower Animal Hospital New Patient Form

When you make your first appointment with Clocktower we ask for some client and patient information. Please print and fill it out in advance and bring it with you to your appointment. All required fields have an asterisk before them.

Owner Information

* Full Name:
* E-mail Address:
Social Security #:
* Home Phone:
Work Phone:
* Address:
* City: * State: * Zip:

Would you like appointment reminders sent by e-mail?
(E-mail reminders are not currently in effect but will be eventually.) Yes No

Spouse or Co-Owner: Work Phone:
Emergency Contact: Home Phone:

How did you hear about Clocktower Animal Hospital?

Referred by
www.clocktowervets.com
Drove by
Washington Consumer's Checkbook
Phone Book/Yellow Pages
Other (please specify)

Names and ages of children living at home (if any):

Are there any other pets in your household? Yes No
If yes, indicate quantity below.

Dog(s) Cat(s)
Bird(s) Reptile(s)
Ferret(s)
Other(s)   (please specify)

Patient Information

* Pet's Name:
* Birth Date:
* Species:
Breed:
Color:

* Sex: Male Female
* Neutered/Spayed?: Yes No

Medical Conditions (allergies, drug reactions, heart conditions, etc.):

Behavior Concerns (chewing, house training, overly aggressive, etc.):

Vaccination History:
Indicate the Month/Year your pet received the following vaccinations:

Canine Distemper/Parvo Caronavirus
Lyme Feline Distemper
Feline Leukemia Bordetella
Rabies
Other (describe)

Nutrition:
What food(s) do you feed your pet?

Dry     Brand
Wet     Brand
Do you feed table scraps? Yes No

Dental Care:
Do you brush your pet's teeth? Yes No
Date of last dental cleaning (if any):

Heartworm Preventative:
Is your pet currently taking Heartworm preventative? Yes No
If yes, is it daily or monthly?
What brand?

If your pet has a Microchip please include their ID number:
Microchip ID Number:

If your pet has a Tattoo please indicate the location and number:
Tattoo Location:
Tattoo Number:

Medical Records:
If seen at another Animal Hospital where can their medical records be obtained?

Payment Policy: All fees are due at the time services are rendered. In addition to cash and personal checks, we accept Visa and MasterCard. A deposit may be required for major medical/surgical cases or trauma/emergency care. Services requiring hospitalization must be paid in full before the animal may be released. In the event of a returned check or non-payment, I agree to be responsible for any finance, collection, or attorney fees.

Our hospital is staffed during the following hours. Staffing during other hours is intermittent.

 

Monday - Friday: 7:00 a.m. - 8:00 p.m.
Saturday: 8:00 a.m. - 4:00 p.m.
Sunday: 10:00 a.m. - 4:00 p.m.

________________________________________ ________________
Signature of Owner or authorized Agent* Date*

* If form is sent to Clocktower Animal Hospital these are to be signed on arrival. If form is printed out you may sign before handing the form in upon arrival.