New Client/New Patient Form (Online) Client InformationThank 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 appointment scheduled for? MM slash DD slash YYYY Appointment Time : AM PM AM/PM 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 AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home PhoneCell 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 PhoneAdditional Authorized Names How did you hear about us?* Sign Google/Online Search Website Next Door App From a Current Client I am a Current Client Other 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 InformationPet #1 Name* First Species* Dog Cat Other If "Other" please indicate in Breed SectionPet #1*BreedDate of BirthColorSex; Spayed or Neutered?Microchipped?Please type "Unknown" if you do not know.Pet #1 DOG Vaccinations History (Last date given)*RabiesDHLP ParvoBordetellasLepto/CoronaFecal (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)*RabiesDIST-RHINO (FVRCP)Feleuk/FIV TestFeleuk VaccinationFecal (Stool Sample)Type "N/A" if you do not know or if it is not a cat.Pet #2 InformationPet #2 Name First Species Dog Cat Other If "Other" please indicate in Breed SectionPet #2BreedDate of BirthColorSex; Spayed or Neutered?Microchipped?Please type "Unknown" if you do not know.Pet #2 DOG Vaccinations History (Last date given)RabiesDHLP ParvoBordetellasLepto/CoronaFecal (Stool Sample)Heartworm Test/Prevention?Leave blank if no additional petsPet #2 CAT Vaccinations History (Last date given)RabiesDIST-RHINO (FVRCP)Feleuk/FIV TestFeleuk VaccinationFecal (Stool Sample)Leave blank if no additional petsPet #3 InformationPet #3 Name First Species Dog Cat Other If "Other" please indicate in Breed SectionPet #3BreedDate of BirthColorSex; Spayed or Neutered?Microchipped?Please type "Unknown" if you do not know.Pet #3 DOG Vaccinations History (Last date given)RabiesDHLP ParvoBordetellasLepto/CoronaFecal (Stool Sample)Heartworm Test/Prevention?Leave blank if no additional petsPet #3 CAT Vaccinations History (Last date given)RabiesDIST-RHINO (FVRCP)Feleuk/FIV TestFeleuk VaccinationFecal (Stool Sample)Leave blank if no additional petsAny previous concerns such as serious illnesses, surgeries, allergies to vaccinations, special diets, or medications to any of your pets?File Drop files here or Select files Accepted file types: pdf, Max. file size: 128 MB. 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 PETSStatement of Financial Policy* I agree to the Statement of Financial PolicyAt Asheville Highway Animal Hospital, we endeavor to render each patient the best possible medical treatement at the lowest possible cost. Threfore, the following financial policies will be strictly enforced. 1. A deposit in proportion to the estimated cost is required upon hospital admission. 2. Payment in full is due upon discharge of the patient. 3. Payments can be made by: Cash, Care Credit, Scratchpay, AmEx, Discover, Mastercard or Visa. 4. A $30.00 service fee will be charged on all returned checks. Please indicate choice 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.No Show Policy I agree to the AHAH No Show Policy.Our veterinarians and staff work very hard to meet the needs of our patients. We kindly ask that you give 24 hour notice if you need to cancel your appointment. As a courtesy, we attempt to leave a reminder message on your answering machine if there is no answer. However, you are responsible for notifying us if you will not be able to make it. Three times consideration will be made for failue to show up for your appointment. Any no shows thereafter will be charged as follows: Client must pre-pay for the appointment at the time of scheduling. This will be non-refundable. No shows will reset January 1st every year. Thank you for your understanding in this matter.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 PolicyAs 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 CommentsThis field is for validation purposes and should be left unchanged.
