New Client/New Patient Form (Online)

Client Information
Thank you for giving us the opportunity to care for your pet(s). So that we may become better acquainted, please complete the following:
Client Information*
- I am an Existing Client
- I am a New Client
Do you have an appointment scheduled already?*
- Yes
- No
If yes, what date and time is your appoint scheduled for?
Date Format: MM slash DD slash YYYY
Appointment Time

: HH

MM
If no, how would you like us to contact you to make an appointment?*
- Phone Call
- Email
- Either Option is fine with me
- N/A
Primary Owner Name*
First Last
The person bringing in the pet is the legal owner of this pet under law. If for any reason you no longer have ownership of this pet in the future, please inform us immediately so we may be able to make a note of it in our system and send records or discuss medical information with any future owner.
Address*
Street Address Address Line 2 City State ZIP Code
Home Phone
Cell Phone*
Email*
Employer*
Is it okay to send text message appointment reminders?*
- Yes
- No
Is it okay to send correspondence via email?*
- Yes
- No
Co-Owner Name
First Last
Under the laws of HIPPA (Health Insurance Portability and Accountability Act), we cannot disclose information about you or your pet to anyone unless otherwise specified by you. The individual listed above and the additional Authorized Names are authorized to make health and financial decisions for all my current pets.
Co-owner's Phone
Additional Authorized Names
How did you hear about us?*
- Sign
- Google/Online Search
- New Resident Letter
- Yellow Pages
- From a Current Client
- Other
- I am a Current Client
If "Other" or "From a Current Client"
Please indicate how you heard about us. We would love to thank the client who told you about us!
Pet #1 Information
Pet #1 Name*
First
Species*
- Dog
- Cat
- Other
If "Other" please indicate in Breed Section
Pet #1*
Breed Date of Birth Color Sex; Spayed or Neutered? Microchipped?
Please type "Unknown" if you do not know.
Pet #1 DOG Vaccinations History (Last date given)*
Rabies DHLP Parvo Bordetellas Lepto/Corona Fecal (Stool Sample) Heartworm Test/Prevention?
Type "N/A" if you do not know or if it is not a dog.
Pet #1 CAT Vaccinations History (Last date given)*
Rabies DIST-RHINO (FVRCP) Feleuk/FIV Test Feleuk Vaccination Fecal (Stool Sample)
Type "N/A" if you do not know or if it is not a cat.
Pet #2 Information
Pet #2 Name
First
Species
- Dog
- Cat
- Other
If "Other" please indicate in Breed Section
Pet #2
Breed Date of Birth Color Sex; Spayed or Neutered? Microchipped?
Please type "Unknown" if you do not know.
Pet #2 DOG Vaccinations History (Last date given)
Rabies DHLP Parvo Bordetellas Lepto/Corona Fecal (Stool Sample) Heartworm Test/Prevention?
Leave blank if no additional pets
Pet #2 CAT Vaccinations History (Last date given)
Rabies DIST-RHINO (FVRCP) Feleuk/FIV Test Feleuk Vaccination Fecal (Stool Sample)
Leave blank if no additional pets
Pet #3 Information
Pet #3 Name
First
Species
- Dog
- Cat
- Other
If "Other" please indicate in Breed Section
Pet #3
Breed Date of Birth Color Sex; Spayed or Neutered? Microchipped?
Please type "Unknown" if you do not know.
Pet #3 DOG Vaccinations History (Last date given)
Rabies DHLP Parvo Bordetellas Lepto/Corona Fecal (Stool Sample) Heartworm Test/Prevention?
Leave blank if no additional pets
Pet #3 CAT Vaccinations History (Last date given)
Rabies DIST-RHINO (FVRCP) Feleuk/FIV Test Feleuk Vaccination Fecal (Stool Sample)
Leave blank if no additional pets
Any previous concerns such as serious illnesses, surgeries, allergies to vaccinations, special diets, or medications to any of your pets?
File
Drop files here or

Accepted file types: pdf.
If you have an electronic medical records from your previous veterinarian, please submit them with your New Client/New Patient form.
PLEASE FILL OUT THIS FORM AGAIN IF YOU HAVE ANY ADDITIONAL PETS
Forms of Payment*
- Trupanion Pet Insurance
- Cash
- Visa
- MasterCard
- Discover
- American Express
- Care Credit
- ScratchPay
All fees are due at the time services are rendered. Due to the Red Flag Rules, we require a matching ID for all credit card payments.
Please be prepared to provide a signature, SSN, and Driver's Licence Number when you come to your appointment. Thank you!*
I agree to provide this information when I come to my appointment.
Signature __________________________________________________

SSN: _______________________________________________________

Driver's License Number: ____________________________________
Consent*
I agree to the Asheville Highway Animal Hospital Policy
As the primary owner of the above animal(s), I am authorized to make decisions pertaining to care and treatment for the aforementioned pet(s). I am at
least 18 years of age. I understand that I am responsible for keeping the authorized names list current. I also understand that by signing this agreement
I will be held financially responsible to Asheville Highway Animal Hospital for rendering of all services and/or goods.
Electronic Signature*
First Last
CAPTCHA
Email
This field is for validation purposes and should be left unchanged.

Client Information

Pet #1 Information

Pet #2 Information

Pet #3 Information

PLEASE FILL OUT THIS FORM AGAIN IF YOU HAVE ANY ADDITIONAL PETS